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Trends in Pediatric Hospitalizations of Children in Washington State by Insurance and Chronic Condition Status, 1991-1998
John M. Neff, MD;
Jeanette Valentine, PhD;
Alice Park, MPH;
Jan Hicks-Thomson, MSW, MPA;
Dimitri A. Christakis, MD, MPH;
John Muldoon, MPA;
Shervin Churchill, MPH
Arch Pediatr Adolesc Med. 2002;156:703-709.
ABSTRACT
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Objective To examine the possible impact of changes in the organization and management
of the Medicaid program on hospitalization patterns for children with chronic
and nonchronic conditions between January 1, 1991, and December 31, 1998.
Design Longitudinal retrospective study of hospitalization patterns of children
in 4 strata: Medicaid, non-Medicaid, chronic conditions, and nonchronic conditions.
Setting Washington State.
Patients Hospital discharge abstract records for all children aged 0 to 17 years
profiled into those with and without a chronic condition, Medicaid, and non-Medicaid
using a diagnosis-based classification system.
Main Outcome Measures Hospitalization and multiple hospitalization rates and length of hospital
stay.
Results In 1991, hospitalization and multiple hospitalization rates were higher
for all Medicaid vs non-Medicaid children. From 1991 to 1998, there was a
decrease in the hospitalization and multiple hospitalization rates for Medicaid
children only. By 1998, rates for Medicaid children approximated those for
non-Medicaid children. This decrease was greater for nonchronically ill children
than for chronically ill children. Total hospitalizations in Medicaid children
decreased by 4.5%. The mean length of stay in 1991 for all Medicaid hospitalized
children was higher than that for non-Medicaid children (6.1 vs 5.1 days).
By 1998, the length of stay decreased for both groups (5.7 vs 4.9 days).
Conclusion The declines in hospitalization and multiple hospitalization rates observed
in Washington State Medicaid children from 1991 to 1998 may be the result
of many statewide efforts to increase access and improve management for this
population.
INTRODUCTION
THERE HAVE been rapidly evolving changes in the delivery systems of
care and the insurance status of children in the United States during the
past decade. The changes in the delivery system have been directed toward
improving coverage and access and decreasing costs through better management.
The insurance status of children aged 0 to 18 years has improved via expanded
Medicaid coverage, with the proportion of children receiving Medicaid increasing
from 12.8% in 1987 to 20.5% in 1996.1 Results
of a 2000 study2 indicate that an additional
3.3 million children have been enrolled in Medicaid owing to the recently
enacted State Child Health Insurance Program. There has been an increasing
number of Medicaid children served by managed care, as enrollment in managed
care now represents nearly 50% of Medicaid enrollees nationwide.3
Because hospitalizations may account for approximately 30% of all health care
expenditures for children, and approximately 50% of expenditures for children
with chronic conditions,4-5 reducing
the number of hospitalizations and the length of stay (LOS) have been the
focus of efforts to decrease costs while expanding coverage.
How children with special health care needs fare in the rapidly evolving
health care system in the United States remains of great concern.6-7 Approximately 18% of children in the
United States have a chronic health condition.8
Although the range of prevalence estimates varies with alternative measures
of chronic conditions, the clinical implications are significant. Compared
with children without chronic conditions, those with chronic conditions require
more health services, use more compensatory devices and prescription medications,
and consume a wide array of nonmedical and community services, including occupational
and physical therapy, home health, and respite care. Functional limitations
can also accompany chronic health conditions.9-10
In 1997, McConnochie et al11 concluded
from their review that the number of hospitalizations in children can be reduced
without affecting quality. In 2000, Dafney and Gruber12
used the National Discharge Survey to assess the impact of Medicaid expansion
on avoidable hospitalizations for children younger than 15 years between 1983
and 1996. The survey samples approximately 250 000 hospital discharges
annually and collects data on diagnosis, procedure codes, discharge status,
LOS, and selected hospital and demographic information. Dafney and Gruber
found that for children, Medicaid hospitalizations classified as avoidable
decreased by 22%. They also demonstrated an increase of 10% in hospitalization
of all Medicaid children and attributed this increase to the expansion in
coverage. Dafney and Gruber did not differentiate admissions by chronic illness
status, and they did not compare Medicaid and non-Medicaid. Also, their estimates
were somewhat imperfect because their small sample size could not correlate
the uneven pattern of Medicaid changes that were occurring in different states
with the uneven sample of children's hospitalizations.
Comparison of hospitalization rates for children with special health
care needs in a region where Medicaid expansion and reform have occurred uniformly
could contribute to our understanding of the impact of Medicaid expansion
and management on a highly vulnerable population of children. The ability
of states to conduct ongoing monitoring of vulnerable children in a rapidly
changing health care environment poses significant challenges because of limitations
in data and methods. Routinely and uniformly collected data on hospitalizations,
available through hospital abstract reporting systems mandated in every state,
can provide a data set useful for these purposes. In 1999, Friedman et al13 proposed using hospital data from the Nationwide
Inpatient Sample of the Health Care Cost and Utilization Project to track
the impact of states' State Children's Health Insurance Program. Individual
states' hospital abstract reporting systems data can be useful in monitoring
children with special health care needs, by tracking temporal and cross-sectional
patterns of inpatient utilization and by classifying the chronic condition
status of the inpatient episode.
In the state of Washington, Medicaid expansion and improved management
of care occurred during the 1990s as part of a planned system for Medicaid
health care reform. The nature of the reforms included increases in enrollment
eligibility, increases in reimbursement for physician and nonphysician primary
care services, and mandatory capitated managed care. The purpose of this study
is to assess the potential impact of these changes on a specific group of
vulnerable children by examining trends in hospitalizations among children
with chronic health conditions during this time of reform. The methodological
approach consists of using a chronic condition classification grouper designed
to identify children with special health care needs to classify hospital discharges
in Washington State between January 1, 1991, and December 31, 1998. Using
Washington's Comprehensive Hospital Abstract Reporting System (CHARS) data,
trends in inpatient utilization are compared for Medicaid and non-Medicaid
children with and without chronic illnesses. This article provides information
that can contribute to understanding the impact of health system changes on
children with chronic health conditions in general, and Medicaid-eligible
children in particular. This article also illustrates a methodological approach
to monitoring inpatient utilization among populations of children receiving
Medicaid.
PARTICIPANTS AND METHODS
STUDY DESIGN
Temporal trends in inpatient utilization for children aged 0 to 17 years
were measured during 1991-1998, comparing chronic condition hospitalizations
with nonchronic condition hospitalizations. Inpatient utilization measures
were compared for discharges in which Medicaid was the expected primary payer
vs all other payers.
CHRONIC CONDITION CLASSIFICATION
The chronic condition status of each hospital discharge was determined
by grouping International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM)
diagnostic codes appearing in the diagnostic coding fields of the UB-92 form,
which represents an abstract of every hospitalization episode occurring throughout
the state. Classification by the ICD-9-CM is based
on the chronic condition codes identified by the National Association of Children's
Hospitals and Related Institutions Classification of Chronic and Congenital
Health Conditions (NACHRI-CCCHC) system (1996 version).14
Occurrence of a chronic condition ICD-9-CM code,
as identified in the 1996 NACHRI-CCCHC system in any of the 9 diagnostic fields
of the UB-92, constituted the basis for classification of the hospital discharge
as either chronic or nonchronic. Both principal and secondary diagnoses were
considered in the classification of each discharge as either a chronic or
nonchronic condition. The 1996 version of the NACHRI-CCCHC contains more than
3500 individual ICD-9-CM codes and 49 major diagnostic
groups. For this study, the major diagnostic group for newborn risk is included
in the nonchronic condition group because newborn risk is no longer considered
a chronic condition category under the NACHRI-CCCHC system. Newborn risk diagnostic
conditions include low-birth-weight, very low-birth-weight, and drug- and
alcohol-involved births.
PAYER CLASSIFICATION
Medicaid payer status was identified from the payer identification field
of the UB-92 form, with the code "002" representing "Medicaid-Washington State
Department of Social and Health Services and/or Healthy Options." Healthy
Options is the state of Washington's managed care program for Medicaid beneficiaries.
Payer identification classified as non-Medicaid represented all payers not
classified as Medicaid, including commercial insurance, workers compensation,
health care service contractors, other sponsored patients (such as the Civilian
Health and Medical Program of the Uniformed Services or the Indian Health
Services), Medicare, and self-pay or charity care.
INPATIENT UTILIZATION MEASURES
Three utilization measures are the subject of this study: (1) hospitalization
rate, (2) average LOS, and (3) multiple hospitalizations rate. Hospitalization
rates were calculated as the number of hospitalization events for the specific
condition in persons aged 0 to 17 years per 100 000 population. The population
aged 0 to 17 years was classified as either enrolled in Medicaid (as estimated
by the Department of Social and Health Services administrative data on monthly
estimates of children receiving Medicaid, regardless of whether they had an
encounter or a billable service) or not enrolled in Medicaid. These population
estimates were used as denominators to calculate population-based hospitalization
rates. The LOS was calculated as the mean number of days per inpatient stay
for the specific condition in persons aged 0 to 17 years. Multiple hospitalization
rates were calculated as the number of persons with more than 1 hospitalization
during a calendar year divided by the population estimates for each of 3 groups—Medicaid
enrolled, non-Medicaid, and total population aged 0 to 17 years. The rate
was then calculated by multiplying by 100 000. Thus, the multiple hospitalizations
rate represents the number of children with multiple hospitalizations per
100 000 population aged 0 to 17 years.
DATA SOURCES
Hospital Discharges
All hospital discharge abstract records for children aged 0 to 17 years,
as reported in the CHARS for the state of Washington for 1991-1998, are included
in this study. Excluded from this set are hospitalizations from US military,
US veterans, and state psychiatric hospitals; birthing centers; and private
alcoholism and rehabilitation facilities. The CHARS is composed of abstracts
of every hospitalization and was used to calculate the hospitalization rates
and LOS. Insurance status is assigned only at the time of discharge. The state
of Washington's Episode of Illness files were available for analysis for 1991-1996
only. These files contain a unique and confidential patient identifier that
allows tracking of multiple hospitalizations for the same individual over
time by linking discharge records with the same identifier. Both data sets
are derived from the UB-92 forms, submitted by all reporting hospitals on
all patient discharges throughout the state. The 9-year CHARS data set was
provided by the Washington State Department of Health Office of Hospital and
Patient Data Systems. The following categories were excluded from the database
for the analysis of inpatient utilization for pediatric chronic conditions:
(1) all normal births with birth weights greater than 2499 g, (2) all teenagers
hospitalized for childbirth only, and (3) non–Washington State residents.
Normal live births were excluded because normal birth-related hospitalizations
do not accurately reflect a hospitalization event for the child and can skew
the information on frequency and cause of childhood hospitalizations. Application
of exclusion criteria resulted in a total of 372 406 discharges among
Washington State residents aged 0 to 17 years during 1991-1998. Of these,
132 516 discharges had Medicaid as the expected primary payer, and 239 890
were non-Medicaid–expected payer discharges. Analysis of unique patient
identifiers indicated that during the 6-year period for which data are available,
28 937 individual pediatric patients had more than 1 hospitalization. Table 1 presents the number of discharges
each year by expected primary payer.
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Table 1. Number of Hospital Discharges in Children Aged 0 to 17 Years,
by Expected Primary Payer, Washington State, 1991-1998
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Population Data
Annual estimates of the total population aged 0 to 17 years for 1991-1998
were provided by the Washington State Office of Financial Management and the
Washington State Adjusted Population Estimates (April 1999) of the Department
of Social and Health Services. Estimates of the number of children enrolled
in Medicaid during 1991-1998 were provided by the Medical Assistance Administration
of the Department of Social and Health Services and were based on monthly
averages of enrolled children from the Medicaid eligibility data files. An
"enrolled" status designates a child who has been determined eligible for
Medicaid, regardless of whether he or she had a billable service.
ANALYSIS
Trends in the 3 inpatient utilization measures were examined during
the 8-year period for chronic and nonchronic condition hospitalizations, stratified
by the 2 categories of expected primary payer: Medicaid vs non-Medicaid (all
discharges after excluding Medicaid). The  2 test for trend
was used to determine the statistical significance level of the observed trends.
All analyses were conducted using SPSS software version 8.0 (SPSS Inc, Chicago,
Ill).
RESULTS
RATE OF HOSPITALIZATION
Figure 1 indicates that the
overall rate of hospitalization in all children aged 0 to 17 years declined
from 3685 per 100 000 population in 1991 to 3041 per 100 000 population
in 1998 (P<.001, 2 test for trend).
Statistically significant declines occurred for chronic condition (from 1465
in 1991 to 1354 in 1998) and nonchronic condition (from 2220 in 1991 to 1686
in 1998) hospitalizations (P<.001), but the amount
of decline was greater in the nonchronic group.
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Figure 1. Rate of hospitalization in children
aged 0 to 17 years, by chronic condition status, Washington State, 1991-1998.
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Figure 2 shows the trends
in the rate of hospitalization in children aged 0 to 17 years for chronic
and nonchronic conditions, comparing hospitalizations for which Medicaid was
the expected primary payer vs all other payers. The largest decline occurred
in Medicaid hospitalizations for nonchronic conditions, from 4729 per 100 000
Medicaid population in 1991, to 1991 in 1998, representing a decline of nearly
60%. The hospitalization rate for chronic conditions for which Medicaid was
the expected payer showed the second highest rate of decline, from 3216 in
1991 to 1684 in 1998 (P<.001, 2
test for trend). There was a slight increase in hospitalization rates for
non-Medicaid children with chronic conditions (1102 in 1991 to 1224 in 1998; P<.001) and a slight decrease in hospitalization rates
for nonchronic non-Medicaid children (1700 per 100 000 non-Medicaid population
in 1991 to 1570 in 1998). For Medicaid children, the overall rate of hospitalization,
regardless of chronic condition status, declined substantially, from 7945
per 100 000 Medicaid population in 1991 to 3666 in 1998 (P<.001, 2 test for trend). The rate of hospitalization
for non-Medicaid children had a modest but statistically significant decline
in this same period, from 2802 to 2794.
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Figure 2. Rate of hospitalization in children
aged 0 to 17 years, by expected payer and chronic condition status, Washington
State, 1991-1998.
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MEAN LOS
In 1991, the mean LOS for all pediatric hospitalizations with vs without
Medicaid as an expected primary payer was 6.1 vs 5.1 days (Figure 3). In 1998, the mean LOS declined to 5.7 for the Medicaid
group (P<.001) and 4.9 for the non-Medicaid group
(P = .02). The mean LOS for Medicaid hospitalizations
is significantly higher in every year compared with that for non-Medicaid
hospitalizations (P<.001 for each year). For Medicaid
chronic condition hospitalizations, the mean LOS was 8.7 days in 1991, declined
to a low of 7.8 days in 1997, and increased to 8.1 days in 1998 (P<.001) (Figure 4). For
non-Medicaid chronic condition hospitalizations, the mean LOS was 7.3 days
in 1991, 6.2 days in 1995, and 6.7 days in 1998 (P<.001).
For Medicaid nonchronic condition hospitalizations, the mean LOS was 4.4 days
in 1991, 3.6 days in 1994 and 1995, and 3.7 days in 1998 (P<.001). There was a slight decline in mean LOS for non-Medicaid
nonchronic condition hospitalizations (P = .01).
The mean LOS for chronic condition hospitalizations is higher than that for
nonchronic condition hospitalizations.
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Figure 3. Mean length of stay for all pediatric
hospitalizations, by expected primary payer, Washington State, 1991-1998.
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Figure 4. Mean length of stay for all pediatric
hospitalizations, by expected primary payer and chronic condition status,
Washington State, 1991-1998.
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RATE OF MULTIPLE HOSPITALIZATIONS
Overall, the rate of multiple hospitalizations in Medicaid children
was significantly higher than for non-Medicaid children from 1991 to 1996
(Figure 5). The Medicaid multiple
hospitalizations rate for children with chronic conditions declined significantly
between 1991 and 1996, from 689 to 367 per 100 000 population (P<.001). The multiple hospitalizations rate for nonchronic
Medicaid children decreased from 426 in 1991 to 200 in 1996 per 100 000
population (P<.001). The rate of multiple hospitalizations
for nonchronic non-Medicaid children declined at a lower rate, from 95 in
1991 to 79 in 1996 per 100 000 population, whereas the rate for chronic
non-Medicaid children increased slightly from 1991 to 1996, from 161 to 175
per 100 000 population.
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Figure 5. Rate of multiple hospitalizations
in children aged 0 to 17 years, by expected primary payer and chronic condition
status, Washington State, 1991-1996.
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COMMENT
Total hospitalization and multiple hospitalizations rates for Medicaid-enrolled
children aged 0 to 17 years in Washington State show a pronounced decrease
from 1991 to 1998. This trend is not as great for non-Medicaid children. Within
the Medicaid population, this decrease in rates is more pronounced for nonchronically
ill compared with chronically ill children, although the downward trends for
both groups are statistically significant. There also is an observed decrease
in hospital LOS for chronically and nonchronically ill children in the Medicaid
and non-Medicaid admissions.
The state of Washington made major efforts between 1989 and 1995 to
improve access to the medical care system for uninsured and Medicaid-eligible
children (Table 2). These efforts
can be summarized as 3 major policy initiatives: (1) increase in enrollment
to Medicaid for more children by increasing the income eligibility from less
than 100% to 200% of the Federal Poverty Level, (2) increase in reimbursement
to physicians, midwives, advanced registered nurses, and nurse practitioners
for fee-for-service primary care visits, and (3) enhanced management through
statewide mandatory enrollment of Medicaid recipients aged 0 to 17 years into
capitated managed care (the Healthy Options program). As a result of these
policy initiatives, the number of 0- to 17-year-old Medicaid enrollees nearly
doubled, from 225 790 in 1991 to 429 971 in 1998.
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Table 2. Initiatives to Improve Access to Primary Care in Children
Aged 0 to 17 Years, Washington State, 1989-1995*
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Most Medicaid enrollees were assigned, for the first time, to a primary
care provider through a Healthy Options plan. In Healthy Options, care was
provided by state contracts through several area-wide health plans. By 1994,
two years after the initiation of mandatory managed care, approximately 50%
of the children receiving Medicaid were assigned to a Healthy Options plan.
This percentage increased to 70% in 1995 and 80% in 1998. Those excluded from
mandatory enrollment were Supplemental Security Income, Foster Care, and institutionalized
children, and a few with special exemptions. During the 1990s, most local
health departments and schools in the state entered into intergovernmental
agreements with Medical Assistance to provide outreach and linkage for pregnant
women and children in their communities. These activities increased enrollment
in Medicaid and, through Healthy Options, linked children to a primary care
provider. The temporal association of decreased utilization of hospitals by
Medicaid enrollees and the state initiatives suggests a cause-and-effect relationship.
Unlike the observation of Dafny and Gruber12
of an increase in child hospitalizations with increased Medicaid enrollment
nationwide, the absolute number of childhood Medicaid hospitalizations in
Washington State decreased from 17 940 to 15 763 as the number of
children enrolled in Medicaid increased by 90%. This decrease suggests that
increased access to insurance and medical care of the uninsured and underinsured,
coupled with improved management, may decrease the total hospital burden carried
by the state. In relatively recent supportive studies,15-17
data indicate that the provision of, and access to, primary care services
among Medicaid beneficiaries reduces the use of emergency department services
and hospitalization.
The more pronounced decrease in hospital use by nonchronically ill compared
with chronically ill children suggests that these actions had a greater impact
on the nonchronically ill than on the chronically ill. The decrease in LOS
is likely the result of many different management efforts. The slight increase
in LOS since 1996 might be explained by a change in severity mix or a change
in some of the management efforts.
Although the actions taken by the state may be the major factor responsible
for these trends, we must acknowledge that there could be other external changes
that we do not have data on that could have affected hospitalizations in the
Medicaid population more than those in the non-Medicaid group. These changes
could include, among others, an improved economy, better home health, and
certain advances in technology. There are other limitations to this study.
The database is limited to utilization measures, and we do not have precise
information on specific factors that could explain these findings. We are
relying on the suggestion that certain changes in the health care system have
had a causal association. These changes in the health care system, however,
have been designed to have exactly the effect on utilization measures that
is observed in this study.
We have limited precision in determining hospitalization rates in chronically
ill children because we do not have a denominator for chronically ill children.
It is not likely, however, that the number of chronically ill children has
changed dramatically in the past decade, and we can presume that the denominator
is the same. We also have limited information on Medicaid children who have
been out of the managed care initiatives, the Supplemental Security Income,
foster children, and others. This group, however, makes up approximately 20%
of the children receiving Medicaid. Improved management of this group might
have resulted in an even more dramatic decline in the observed total Medicaid
hospitalization rates.
The reliability of Medicaid entries in the hospital record is unknown.
It is possible that when Medicaid entered into contractual agreements with
private health care plans, Medicaid patients were recorded as non-Medicaid
in the hospital database. Analysis of the data does not support this possibility.
The absolute number of hospital discharges has declined for discharges classified
as either "Medicaid expected primary payer" or "non-Medicaid expected primary
payer." If the payer status was being misclassified, we could expect to see
a decrease in the Medicaid-classified discharges and a comparable increase
in the non-Medicaid–classified discharges, but this is not the case.
An alternative explanation for these results, that is, a dramatic decline
in inpatient utilization among pediatric chronic condition discharges, is
the possibility that the increased enrollment of Medicaid beneficiaries may
have changed the severity composition of that population into a healthier
group, and thus we would expect less need for hospitalizations. However, this
possibility seems unlikely because we did not observe a corresponding increase
in hospitalization rates in the non-Medicaid population during this time of
rapid enrollment. It is still possible that misclassification of discharges
and a change of severity composition could have affected these findings to
some degree.
Uninsured children are included in the non-Medicaid population, and
the database does not allow separate identification of that population. This
is a group of children who might be expected to have high utilization of hospital
services but who, combined with the non-Medicaid population, demonstrate low
hospital admission rates. A factor that might explain this is that children
without insurance do not interact with the health care system until they have
a serious condition. When hospitalization occurs, the child is likely to be
enrolled and discharged on Medicaid and some type of managed care. The discharge
status is the information that is recorded in the CHARS data set. The child
will show up in the denominator as non-Medicaid but in the numerator, on discharge
from the hospital, as receiving Medicaid. Once the child is in some type of
managed care, the chance for further hospitalizations may be reduced.
We do not have reliable data on the hospitalization patterns for children
in Washington State before 1991. The trends observed in this study might be
long-term trends because the state had made some efforts, but not as intense,
in previous years to improve primary care and discharge planning for all children.
The period of this study, however, demonstrates striking changes, with hospitalization
rates in the Medicaid population decreasing by nearly 50%, and, by 1997, closely
approximating the rates in the non-Medicaid population.
A strength of this study is the comprehensiveness of the database. The
CHARS data from the state of Washington represent nearly 100% of discharges
for all children since 1991, excluding information from military and psychiatric
hospitals only, and there is good information from the state agencies on the
total Medicaid population. These data have allowed us to calculate hospitalization
rates for the Medicaid and non-Medicaid population groups during the time
of statewide health care reform for Medicaid children.
These results may be generalizable to other regions of the country.
Washington State is not atypical regarding initiation of mandatory capitated
managed care or initiatives directed toward increasing access of Medicaid
children to primary care providers. This method can be replicated in other
states that have these data sets available and can be refined to monitor long-term
trends in hospital use.
Although it is not clear what has led to this decrease in the number
of Medicaid hospitalizations, it seems that the combination of some type of
collective action has had a significant effect on hospitalization patterns.
It also seems that in the next decade there may not be such reductions in
hospital utilization but, at best, stabilization. The observations from this
study are that by 1998, there are little differences between the Medicaid
and the non-Medicaid hospitalization rates. These rates seem to be stabilizing—a
higher percentage of those admitted have chronic conditions, and LOS is increasing
slightly toward the end of the study. Ongoing analysis of these trends should
continue to provide more clarity on the effects of health care legislation.
The findings also caution that any legislative or administrative efforts that
could directly or indirectly change the health care reform measures of the
1990s must be approached carefully to avoid returning to high hospital utilization.
| What This Study Adds
There have been dynamic changes in enrollment to Medicaid programs and
in management of health care during the past decade. These changes have been
designed to increase access to primary care and to decrease hospital utilization.
There is limited information about concurrent and subsequent patterns of hospitalization.
In the state of Washington during a time of increased enrollment of
children into Medicaid and improved management of care, there have been marked
decreases in Medicaid hospitalization rates and total hospitalizations for
children with chronic and nonchronic conditions.
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AUTHOR INFORMATION
Accepted for publication March 14, 2002.
This study was supported by grant 5 H16 MC 00040-03 from Health Resources
Services Administration of the US Department of Health and Human Services,
Bethesda, Md, and by a contract with the Washington State Department of Health
Children With Special Needs Program.
Hospital inpatient data were made available by the Washington Department
of Health's Office of Hospital Data Systems. Estimates of children enrolled
in Washington's Medicaid program were provided by the Washington Department
of Social and Health Services. Population data were provided by the Office
of Financial Management of the State of Washington, Olympia.
We thank Sherilynn Casey, MPA, of the Department of Health and Roger
Gantz, MUP, of the Medical Assistance Administration of the Washington State
Government for providing information on Washington State health initiatives
and Patty Centioli for her patient preparation of this manuscript.
Corresponding author and reprints: John M. Neff, MD, Center for Children
With Special Needs, Children's Hospital and Regional Medical Center, 4800
Sand Point Way NE, CM-09, Seattle, WA 98105-0371 (e-mail: jneff{at}chmc.org).
From the Center for Children With Special Needs, Children's Hospital
and Regional Medical Center, Seattle, Wash (Drs Neff and Valentine, Ms Park,
and Ms Churchill); the Department of Health, Washington State, Olympia (Ms
Hicks-Thomson); the Child Health Institute (Dr Christakis) and the Department
of Pediatrics (Drs Neff and Christakis), University of Washington, Seattle;
and the National Association of Children's Hospitals and Related Institutions,
Alexandria, Va (Mr Muldoon).
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