1 00:00:00,000 --> 00:00:01,919 This is Chris Sosa with the Becker's Healthcare 2 00:00:01,919 --> 00:00:02,419 podcast. 3 00:00:02,720 --> 00:00:04,400 And today, we'll be joined by doctor Scott 4 00:00:04,400 --> 00:00:07,200 Krugman, director of pediatric operations at Herman and 5 00:00:07,200 --> 00:00:10,320 Walter Samuelson Children's Hospital at Sinai. Doctor Krugman, 6 00:00:10,320 --> 00:00:11,699 thank you for joining us today. 7 00:00:12,000 --> 00:00:14,505 Thanks for having me. Excellent, doctor. Would you 8 00:00:14,505 --> 00:00:16,425 please introduce yourself and give us a bit 9 00:00:16,425 --> 00:00:17,324 about your background? 10 00:00:17,945 --> 00:00:20,765 Yeah. So I am a, general pediatrician, 11 00:00:21,225 --> 00:00:25,164 and I have been in, pediatric leadership positions 12 00:00:25,385 --> 00:00:26,519 for many years. 13 00:00:26,920 --> 00:00:29,100 I ran a department of pediatrics 14 00:00:29,640 --> 00:00:32,119 at a community hospital in Baltimore County for 15 00:00:32,119 --> 00:00:32,940 20 years, 16 00:00:33,799 --> 00:00:35,420 and did that with, 17 00:00:35,799 --> 00:00:37,960 I thought great success until they decided to 18 00:00:37,960 --> 00:00:40,219 close pediatrics in, 2018. 19 00:00:41,024 --> 00:00:42,704 And since then, I've been at the Children's 20 00:00:42,704 --> 00:00:45,185 Hospital at Sinai in Baltimore where I've been 21 00:00:45,185 --> 00:00:47,125 vice chair of pediatrics and now, 22 00:00:47,505 --> 00:00:49,825 the director of pediatric operations because I hold 23 00:00:49,825 --> 00:00:52,384 another hat, which is a a senior associate 24 00:00:52,384 --> 00:00:54,545 dean for the George Washington University School of 25 00:00:54,545 --> 00:00:56,759 Medicine where we're now a regional medical campus 26 00:00:56,759 --> 00:00:57,659 for that school. 27 00:00:58,280 --> 00:00:59,799 Thank you for laying all that out for 28 00:00:59,799 --> 00:01:02,280 us, doctor. And you touched on briefly the 29 00:01:02,280 --> 00:01:04,759 subject that we wanna touch today. And the 30 00:01:04,759 --> 00:01:06,519 question I have for you, just to get 31 00:01:06,519 --> 00:01:08,840 things started, is from your perspective, could you 32 00:01:08,840 --> 00:01:11,575 please detail the challenges that pediatric inpatient units 33 00:01:11,575 --> 00:01:13,354 are facing and why some are closing? 34 00:01:13,894 --> 00:01:16,375 Yeah. So this has been going on for 35 00:01:16,375 --> 00:01:18,875 a couple decades sort of under the radar. 36 00:01:19,414 --> 00:01:21,814 But over the past 5 to 7 years, 37 00:01:21,814 --> 00:01:25,114 if you're paying attention to the, Becker's Weekly 38 00:01:26,560 --> 00:01:28,740 notifications that a lot of us get, 39 00:01:29,120 --> 00:01:31,200 more and more often you're seeing that pediatric 40 00:01:31,200 --> 00:01:33,920 units are closing. And the reason is that 41 00:01:33,920 --> 00:01:36,740 community hospitals really have a hard time, 42 00:01:37,680 --> 00:01:38,180 supporting 43 00:01:38,560 --> 00:01:41,780 a money losing venture, which is inpatient pediatrics. 44 00:01:42,435 --> 00:01:44,135 It costs a lot of money to 45 00:01:44,435 --> 00:01:44,935 staff 46 00:01:45,474 --> 00:01:46,855 units with pediatricians, 47 00:01:47,474 --> 00:01:49,575 with pediatric specific nurses, 48 00:01:50,115 --> 00:01:53,734 and most pediatric units in community settings will 49 00:01:54,034 --> 00:01:57,560 have very variable volume. So at one point 50 00:01:57,560 --> 00:01:59,159 in the middle of winter, there might be 51 00:01:59,159 --> 00:02:01,260 10 kids on their unit and they're overflowing. 52 00:02:01,799 --> 00:02:03,740 In the summer, there might be one child. 53 00:02:04,120 --> 00:02:06,520 Sometimes, the variation goes from day to day, 54 00:02:06,520 --> 00:02:08,280 whereas one day it's full, the next day 55 00:02:08,280 --> 00:02:10,814 it's empty. And to staff that kind of 56 00:02:10,814 --> 00:02:13,314 unit is very, very challenging because 57 00:02:13,854 --> 00:02:16,495 nothing in pediatric works on a average daily 58 00:02:16,495 --> 00:02:16,995 census. 59 00:02:17,294 --> 00:02:19,375 Whereas, if you have a hospital that has 60 00:02:19,375 --> 00:02:20,834 multiple adult units, 61 00:02:21,134 --> 00:02:23,694 usually, the average doesn't vary that much that 62 00:02:23,694 --> 00:02:24,754 you can predictably 63 00:02:25,080 --> 00:02:26,860 staff with nursing and doctors 64 00:02:27,400 --> 00:02:29,000 how to run those units, or you can 65 00:02:29,000 --> 00:02:31,159 flex people from one to another. But, typically, 66 00:02:31,159 --> 00:02:32,379 in community hospitals, 67 00:02:32,680 --> 00:02:34,840 there's only 1 pediatric unit, and there's nowhere 68 00:02:34,840 --> 00:02:36,379 to flex people to. So 69 00:02:36,680 --> 00:02:37,979 the costs are 70 00:02:38,504 --> 00:02:39,564 higher than expected. 71 00:02:39,944 --> 00:02:42,584 And, of course, we're dealing with hospital based 72 00:02:42,584 --> 00:02:44,985 revenue. And depending on what state you're on, 73 00:02:44,985 --> 00:02:46,905 things vary a lot. But for the most 74 00:02:46,905 --> 00:02:50,205 part, pediatrics is not high end 75 00:02:50,905 --> 00:02:51,805 money making 76 00:02:52,290 --> 00:02:55,810 procedures like neurosurgery and orthopedic surgery. So for 77 00:02:55,969 --> 00:02:57,889 when the hospital is looking at their bottom 78 00:02:57,889 --> 00:02:59,969 line, the easiest thing to cut off in 79 00:02:59,969 --> 00:03:01,110 is inpatient pediatrics. 80 00:03:02,530 --> 00:03:04,370 Thank you so much for laying out all 81 00:03:04,370 --> 00:03:07,030 those challenges, and, clearly, there are many. 82 00:03:07,605 --> 00:03:09,205 Doctor, the next thing I wanna ask you 83 00:03:09,205 --> 00:03:10,745 is given those challenges, 84 00:03:12,085 --> 00:03:14,325 what are the ripple effects of pediatric inpatient 85 00:03:14,325 --> 00:03:15,224 units closing 86 00:03:15,764 --> 00:03:16,264 respectful 87 00:03:16,805 --> 00:03:19,365 respective to both the children and the communities 88 00:03:19,365 --> 00:03:20,185 where they live? 89 00:03:20,530 --> 00:03:23,009 Yeah. And this is where things are starting 90 00:03:23,009 --> 00:03:23,489 to, 91 00:03:23,810 --> 00:03:25,409 come to a head, and they really came 92 00:03:25,409 --> 00:03:27,349 to a head during COVID time when 93 00:03:27,650 --> 00:03:30,689 we had the initial lockdown and pediatric volumes 94 00:03:30,689 --> 00:03:32,384 plummeted, and a lot of units 95 00:03:32,864 --> 00:03:35,905 closed, shut down, some temporarily, some not. But 96 00:03:35,905 --> 00:03:38,004 the year after, we had a huge respiratory 97 00:03:38,144 --> 00:03:40,704 viral surge in pediatrics, and kids were being 98 00:03:40,704 --> 00:03:41,604 sent all over, 99 00:03:43,344 --> 00:03:45,104 all from state to state and all over 100 00:03:45,104 --> 00:03:47,629 the world you know, all over farther away 101 00:03:47,629 --> 00:03:49,710 to get care because there were not enough 102 00:03:49,710 --> 00:03:51,550 beds in the area anymore. So what we're 103 00:03:51,550 --> 00:03:52,530 seeing is, 104 00:03:53,229 --> 00:03:55,629 especially in rural areas but also in many 105 00:03:55,629 --> 00:03:58,770 suburban areas, that the local hospital that closes, 106 00:03:59,275 --> 00:04:01,615 children have to go farther to seek definitive 107 00:04:01,675 --> 00:04:03,754 care. So we're seeing an increase in number 108 00:04:03,754 --> 00:04:05,675 of kids who are being transferred from one 109 00:04:05,675 --> 00:04:06,655 hospital to another, 110 00:04:07,355 --> 00:04:10,155 increasing number of kids who are being cared 111 00:04:10,155 --> 00:04:11,935 for at children's hospitals, 112 00:04:12,549 --> 00:04:13,610 and that consolidation 113 00:04:13,989 --> 00:04:16,250 is really having an effect that it takes, 114 00:04:17,110 --> 00:04:19,350 the the care that was once able to 115 00:04:19,350 --> 00:04:21,269 be delivered in the community out of the 116 00:04:21,269 --> 00:04:21,769 community. 117 00:04:22,149 --> 00:04:25,209 And because those hospitals are doing less children, 118 00:04:25,384 --> 00:04:28,345 less pediatric care in general, we're finding that 119 00:04:28,345 --> 00:04:31,785 most emergency departments in community settings are not 120 00:04:31,785 --> 00:04:32,285 prepared 121 00:04:32,824 --> 00:04:34,584 to take care of kids. So the most 122 00:04:34,584 --> 00:04:36,985 recent data is that 80% of hospitals are 123 00:04:36,985 --> 00:04:37,144 not 124 00:04:38,310 --> 00:04:40,790 have do not have the guidelines and the 125 00:04:40,790 --> 00:04:42,569 procedures and the equipment 126 00:04:42,949 --> 00:04:45,930 to successfully care for kids, and that's causing 127 00:04:46,230 --> 00:04:48,550 potentially bad effects of kids not getting the 128 00:04:48,550 --> 00:04:50,970 care they need or having bad outcomes like, 129 00:04:51,430 --> 00:04:54,024 worse morbidity or mortality because they're not ending 130 00:04:54,024 --> 00:04:56,264 up in a place initially who has is 131 00:04:56,264 --> 00:04:57,944 the bill has the ability to care for 132 00:04:57,944 --> 00:04:58,444 them. 133 00:04:59,384 --> 00:05:01,144 At this point in time, doctor, what are 134 00:05:01,144 --> 00:05:03,144 the steps that you think health care leaders 135 00:05:03,144 --> 00:05:05,545 and others, whether it be legislators or other 136 00:05:05,545 --> 00:05:06,444 leaders in 137 00:05:06,759 --> 00:05:09,240 certain positions, what can they do to improve 138 00:05:09,240 --> 00:05:09,980 this situation? 139 00:05:10,839 --> 00:05:14,300 So we haven't really had very large conversations 140 00:05:14,920 --> 00:05:17,080 as a society about how we wanna care 141 00:05:17,080 --> 00:05:17,720 for kids. 142 00:05:18,040 --> 00:05:20,459 It's always an afterthought. Most of 143 00:05:20,824 --> 00:05:22,584 the models that have been put in place 144 00:05:22,584 --> 00:05:24,605 to reduce costs around hospital 145 00:05:25,145 --> 00:05:27,645 care have been done so around the Medicare 146 00:05:27,705 --> 00:05:30,105 population for good reason because they cost a 147 00:05:30,105 --> 00:05:30,845 lot of money. 148 00:05:31,705 --> 00:05:34,105 So we need to decide if we wanna 149 00:05:34,105 --> 00:05:35,805 care for kids or not and what 150 00:05:36,329 --> 00:05:38,970 what number of hospitals and what sort of 151 00:05:38,970 --> 00:05:41,449 distances are we is acceptable for kids to 152 00:05:41,449 --> 00:05:42,589 get care. And 153 00:05:42,970 --> 00:05:44,990 if we went from it from a 154 00:05:45,370 --> 00:05:47,370 standpoint of what's in the best interest of 155 00:05:47,370 --> 00:05:50,314 kids, we could design a completely different system 156 00:05:50,314 --> 00:05:52,495 in this whole in our whole country. And 157 00:05:52,875 --> 00:05:56,574 the problem is unless we have better payment 158 00:05:56,634 --> 00:05:57,134 mechanisms 159 00:05:57,435 --> 00:06:00,475 for pediatric care, there is not gonna be 160 00:06:00,475 --> 00:06:03,274 any impetus to change, and pediatrics is gonna 161 00:06:03,274 --> 00:06:05,680 have to end up being a community benefit 162 00:06:05,680 --> 00:06:06,180 or, 163 00:06:06,959 --> 00:06:09,779 a loss leader that a hospital might tolerate. 164 00:06:10,319 --> 00:06:13,120 And my recommendation to local hospitals is decide 165 00:06:13,120 --> 00:06:14,879 if you're in or not. And if you're 166 00:06:14,879 --> 00:06:17,295 not in, what are the mechanisms you're gonna 167 00:06:17,375 --> 00:06:18,975 put in place to make sure kids are 168 00:06:18,975 --> 00:06:21,694 getting safe care? And I I don't know 169 00:06:21,694 --> 00:06:24,254 how often those conversations are happening, but the 170 00:06:24,254 --> 00:06:26,654 more that those can happen, I think we're 171 00:06:26,654 --> 00:06:28,675 gonna be in a much better place. And 172 00:06:29,134 --> 00:06:31,715 we really need to have a a structure 173 00:06:31,775 --> 00:06:34,569 in place that puts the kids first and 174 00:06:34,569 --> 00:06:36,970 puts the payment for those services first so 175 00:06:36,970 --> 00:06:39,529 that we can assure that, you know, in 176 00:06:39,529 --> 00:06:40,189 a certain 177 00:06:40,730 --> 00:06:43,449 rural area, kids have a point access to 178 00:06:43,449 --> 00:06:45,209 care, and then there might be a, like, 179 00:06:45,209 --> 00:06:47,274 a a, like, a spoke part, and then 180 00:06:47,274 --> 00:06:48,475 there's a hub where they need to go 181 00:06:48,475 --> 00:06:49,995 if they actually need to go there. But 182 00:06:49,995 --> 00:06:51,435 if it's something simple, they can stay in 183 00:06:51,435 --> 00:06:53,274 their community, which is better for the family 184 00:06:53,274 --> 00:06:54,495 and better for the child. 185 00:06:55,274 --> 00:06:57,435 Doctor, thank you so much for sharing your 186 00:06:57,435 --> 00:06:59,595 time and insights with us today. We're gonna 187 00:06:59,595 --> 00:07:01,035 get them out to our audience as soon 188 00:07:01,035 --> 00:07:03,027 as possible, and we look forward to connecting 189 00:07:03,027 --> 00:07:04,867 with you again soon. Thank you so much 190 00:07:04,867 --> 00:07:05,767 for having me.