Reduced Health Care Expenditures in a Medical Home for Children in Foster Care

Background: Children in foster care (CFC) are at increased risk for fragmented care and medical complexity, which may be associated with higher health care costs than the general pediatric population. Providing assessment and primary care in a trauma-informed medical home setting could improve access and continuity of care, as well as communication among stakeholders in the care of children in this special-needs population. Studies of the patient-centered medical home (PCMH) model have shown mixed effects on health care costs, but CFC present specific challenges to managing cost, particularly timely access to initial assessment and ongoing primary care. The FRESH Start clinic (FSC) provides primary care to CFC as a trauma-informed PCMH within an academic community-based pediatric clinic with integrated behavioral health. We compared costs and utilization among children managed at FSC with matched CFC managed in the community.

Methods: We queried the Alabama Medicaid claims database for 2016-2018 to compare health care costs among children seen in FSC with matched CFC seen in other community settings. We compared claims for 72 FSC patients and 109 control CFCs matched by gender, race/ethnicity, age, complex chronic condition, number of months of claims available, and county of residence.

Results: Fresh Start children, when compared to controls, had no differences in mean number of visits in any healthcare service category but had greater odds of inpatient expenditures for ACSC conditions, though these expenditures were significantly lower than controls. FSC children also had significantly lower pharmacy expenditures despite similar number of claims. Overall, FSC children are predicted to have annual total expenditures $986 lower than controls. If all 12,668 youth in foster care of at least infant age received care in a clinic like Fresh Start, Alabama Medicaid could expect to see a decrease of $12,490,000 in annual expenditures.

Conclusion: Overall, children seen at FSC incurred lower health care costs during the study period than matched CFC statewide, despite similar utilization. The lower hospital cost is commensurate with previous literature on PCMHs, but there is insufficient data to explain this in our study group, given the small number of total admissions. The pharmacy cost savings despite similar number of claims are consistent with other studies of CFC, especially related to psychoactive medications. Enhanced access to trauma-informed primary care and integrated behavioral health could explain the lower prescribing in the FSC group. Future research should focus on describing the types of health care settings where CFC in low-resource regions receive initial assessments and ongoing primary care, clarifying which medications contribute to high pharmacy cost in this population, and evaluating causes of inpatient cost differentials.