Cost of Care for Congenital Heart Disease in a Medicaid Population

Background: Congenital heart disease (CHD) is the most common congenital anatomical defect. Although most pediatric hospitals continue to be paid in a fee-for-service model, value-based contracts with payers are becoming more common. As patients with CHD are costly to care for, understanding the financial makeup of this group of patients is critical in managing a value-based contract. Therefore, we sought to understand the total spend associated with CHD in a Medicaid population within a new sub-capitated payment model in our system.

Methods: This was a retrospective cross-sectional analysis of deidentified patients, newborn to 19 years of age, enrolled in a single Ohio Managed Care Plan in the Southwest region of Ohio. All medical claims were analyzed for the care given between July 2019 and December 2020. We calculated the total spend for this population and the total spend for patients with a diagnosis code associated with a CHD. Patients with isolated patent ductus arteriosus as their only CHD diagnosis were excluded from the CHD group analysis. We also compared the spend for the CHD population with spend in other chronic populations.

Results: Over the 18-month time period, the total spend for this entire Medicaid population of 115,345 pediatric patients was $370,061,263 or $178 per patient per month. Of those enrolled in this cohort, 799 patients (0.7%) had diagnostic codes indicating CHD. The healthcare claims for this group totaled $39,266,359, or $2,730 per CHD patient per month, which accounted for 10.6% of the Medicaid population’s total spend. The top 3% of CHD patients (n=24) by spend accounted for $17,008,384 (43.3%) of total CHD spend. Despite being a small patient population, total spend in the CHD population was similar to total spend in depression (n=2,797; spend ~$34M) and asthma (n=5,818; spend ~$32M).

Conclusion: Our results highlight the importance of the healthcare spend for patients with CHD in a pediatric capitated payment model. Understanding the financial implications of patients with CHD will allow targeted interventions to increase overall value in care for this group.