The Geography of Care

This dispatch explores the ramifications of reorganizing pediatric care around financial logic.

Signal

I’m sure you’ve seen it: pediatric practices being swallowed by Big Health, and inpatient pediatric units in your community “restructuring” or closing altogether. Between 2008 and 2022, US hospitals lost nearly 30 percent of their pediatric inpatient units, compared with only 4.4 percent of adult units. Though alarming, this number is not surprising. Children are far more likely than working-age adults to be covered by Medicaid, and adult beds generally produce more revenue than pediatric beds.

To be clear, PICU beds are not disappearing altogether; they are being consolidated and absorbed into major children’s hospitals. Pediatric critical care beds have actually increased in that same period. Still, that does not erase the closures. It outlines that beds, specialists, money, and institutional knowledge and power are being concentrated, while rural communities and lower-resourced families are left farther away from care.

Today’s field notes will examine the arithmetic of that consolidation and the plans corporate healthcare uses to protect revenue when pediatric services no longer serve the bottom line.

Sometimes it’s a hedge. Sometimes it’s an amputation.

Hopefully, if I do my job correctly, I can communicate one thing very clearly, using this example as evidence. The healthcare system is not broken; it is working exactly as designed. The problem is our reasonable expectations: expecting a healthcare system that has our good in mind, which are not consistent with what is really happening.

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Field Notes

The Hippocratic Revolt exists to expose the mechanism: the corporatization of American healthcare and its replacement of the care model with the revenue model. That mechanism has produced two casualties. One is harm to the health of the population the system claims to serve. The other is the moral degradation and philosophical anemia of healers in medicine.

Pediatrics gives us a clean look at how the mechanism works.

A pediatric inpatient unit is more than a series of small beds; it is an amalgamation of specialists, nurses, respiratory therapists, and clinical pharmacists. Additionally, the unit requires child-size equipment and a system prepared to respond when a child arrives ill at two in the morning. These are specialty units that require specialized staff to treat patients with nuanced physiology and anatomy; this is highly specialized care.

Between 2008 and 2022, the number of pediatric inpatient units in the US fell from 1,749 to 1,226, a decline of 29.9 percent. Pediatric beds fell 19.5 percent. Over the same fourteen-year period, adult inpatient units fell only 4.4 percent, and adult beds declined 3 percent.

The pandemic did not create this trend. Before 2020, pediatric units were already declining by approximately 2.2 percent year over year, with pediatric beds declining by nearly 1.5 percent annually. The pandemic may have been a catalyst, but the amputation had already begun.

The Arithmetic

Hospitals are not confused about why they are making these decisions. They are “good at maths,” as my British colleague might say.

Approximately 37 percent of American children were covered through Medicaid or CHIP in 2024. Medicaid is essential to pediatric care, but payment rates are generally lower than those of commercial payers. Pediatric hospitals must maintain specialized staff, equipment, and readiness even when the unit is not at capacity.

Adult beds generally produce more revenue; pediatric beds generate less. Removing entire pediatric units occurs not because the hospital hates pediatric patients, but because the numbers don’t add up. Frankly, hospital systems give very little thought to individual patients. What they do care about is assigning value to each bed, then comparing the possible revenue from these assets. This disconnected decision-making puts a chasm between the boardroom and the exam room, yet care is shaped nonetheless.

Geography of the PICU

Interestingly, the number of PICU beds across the country increased by 16 percent between 2008 and 2018. In the same period, the number of institutions offering PICU services fell from 358 to 349. In other words, the country added critical-care capacity without meaningfully expanding the number of places offering that care. General pediatric capacity is shrinking locally while highly specialized pediatric capacity is growing and becoming concentrated in major centers. The increase in PICU beds is positive. Institutions such as Texas Children’s, CHOP, Boston Children’s, and Seattle Children’s provide essential pediatric critical care, and there are legitimate clinical advantages to concentrating complex care in centers with deep expertise. But that capacity is not evenly distributed. By 2016, just 63 hospitals, representing 18 percent of hospitals with PICUs, contained 47 percent of the nation’s PICU beds. The result is a system that is more capable in aggregate but less accessible in individual communities.

The Cost of Consolidation

Understanding the geography of the PICU is important for identifying gaps in available care. Even though PICU capacity has increased, access remains disproportionate. Just because the total number of beds in the U.S. has increased does not mean that the PICU is accessible where a child lives. Over many years, structural changes led to almost one-quarter of U.S. children living farther from the nearest pediatric inpatient unit, and rural inpatient beds declined more significantly than urban beds. According to a 2025 national geospatial analysis published in Academic Pediatrics, 20.5 percent of U.S. children live more than 60 minutes away from PICU services. Children in rural and lower-opportunity communities were significantly more likely to face those longer travel times.

Consequently, a large proportion of pediatric critical care depends on interfacility transportation. Nationally surveyed PICUs reported that roughly three in ten admissions arrived directly from another institution. This transportation time, up to an hour or more, can delay care and important medical interventions. When PICU capability is geographically concentrated, access increasingly depends not just on whether a bed exists, but on whether a sick child can be stabilized and physically transported to that bed.

Pediatric Readiness

In pediatric care, a hospital’s pediatric readiness is critical to a child’s survival. A 2019 Pediatrics study reveals that hospitals with the lowest readiness had a mortality rate of 11.1%. Pediatric readiness is not a measure of whether a hospital has a PICU or is considered “safe.” It measures whether the emergency department has the personnel, training, protocols, equipment, medications, and systems necessary to recognize and stabilize a critically ill child. The National Pediatric Readiness Project helped develop the Weighted Pediatric Readiness Score (wPRS) to assess a hospital’s readiness; a score of 88 was the analytic threshold, and hospitals above this threshold were considered to have high pediatric readiness. However, after analyzing 4,840 U.S. Emergency departments, only 17.4% met the high-readiness threshold, a sobering statistic. This does not mean that only 842 hospitals were ready to care for pediatric patients; it means that hospitals meeting the high-readiness threshold were associated with substantially lower mortality among critically ill pediatric patients.

Conclusion

In summation, pediatric capacity has shifted, PICU capability has concentrated, and many children live farther from that capability than they have in years. However, the harm is not merely that care is “far away”; the restructuring and redistribution of care has shifted distance, transfer burden, dependence on local stabilization, and clinical risk onto the patient and family. In critically ill pediatric patients, competence, readiness, and time are of the utmost importance to a child’s mortality risk. When care is redistributed in ways that increase distance, dependence on transfers, and exposure to hospitals with lower pediatric readiness, the burden borne by the patient changes accordingly. These are not simply geographic inconveniences; they are consequences of how the system has chosen to organize care. Which begs the question: What obligation does medicine have when its economically rational structure creates such burdens?

Philosophy of Medicine

Hippocratic philosophy emphasizes a core principle: to help others or, at a minimum, avoid causing them harm. Measured against that standard, we have fallen astray; modern medical systems cause real harm while still claiming to improve population health. The Hippocratic principle places a moral restraint on action: when the system's pursuit of efficiency, growth, or revenue creates avoidable barriers to care, doing less may be more faithful to medicine than continuing unquestioningly. But before we can decide whether medicine has strayed from that principle, we must examine the questions we ask about what the system is doing and why.

 

The world of philosophy is one of asking probing questions. I use the heuristic of thinking of them as first-order, second-order, and third-order questions. Put another way, the surface-level question rarely gets to the heart of the matter, and so I feel the need to dig deeper. In this setting, a first-order question asks, why are pediatric units closing? A good question, but it doesn’t get to the meat and potatoes, as it were. The second-order question presses: Why do we accept profitability as a legitimate determinant of whether a community retains pediatric care? Finally, the third-order question demands: What obligations does a healthcare institution have to provide necessary care when doing so is economically challenging? The deeper we go, the less this is about pediatric beds and more about what medicine is obligated to provide.

The work in the philosophy of medicine asks us to look beyond the surface and examine the assumptions that make this way of organizing and justifying healthcare possible. Pediatric units are closing, but the deeper concern is what their closure reveals about the values governing American healthcare. If access to necessary care becomes negotiable when it is economically challenging, then we ought to ask what, exactly, our healthcare institutions are for.

Intelligence in Circulation

Here is what I have been reading while thinking about this topic, and here is what might sharpen your thinking too:

• Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care
  Newgard CD, Lin A, Malveau S, et al. JAMA Network Open. 2023.
  Nearly 800,000 pediatric emergency encounters examining the relationship between pediatric readiness and mortality. If you read one study from this dispatch, make it this one. Full Text
• Availability of Pediatric Inpatient Services in the United States
  Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Pediatrics. 2021.
  A useful look at the structural side of the problem: shrinking pediatric inpatient capacity, increasing PICU capacity, rural losses, and growing distance between children and inpatient care. Full Text
• Pediatric Readiness in the Emergency Department
  Remick KE, Foster AA, Jensen AR, et al. Pediatrics. 2026.
  The technical report behind the concept of pediatric readiness. It explains what readiness actually requires: trained personnel, pediatric equipment, medications, protocols, transfer systems, and the infrastructure necessary to stabilize a critically ill child. Full Text

References:

I. Pediatric Economics, Capacity, and Consolidation

1. Michelson KA, Cushing AM, Bucholz EM. National trends in pediatric inpatient capacity. JAMA Pediatr. 2025;179(2):208-209. doi:10.1001/jamapediatrics.2024.5110
2. Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of pediatric inpatient services in the United States. Pediatrics. 2021;148(1):e2020041723. doi:10.1542/peds.2020-041723
3. Joseph AM, Davis BS, Kahn JM. Association between hospital consolidation and loss of pediatric inpatient services. JAMA Pediatr. 2023;177(8):859-860. doi:10.1001/jamapediatrics.2023.1747
4. San Soucie CM, Beaulieu ND, Buxbaum JD, et al. A national analysis of general pediatric inpatient unit closures and openings, 2011-2018. Hosp Pediatr. 2024;14(11):899-908. doi:10.1542/hpeds.2024-007754
5. Riese J, Alverson B. The role of financial drivers in the regionalization of pediatric care. Pediatrics. 2021;148(1):e2021050432. doi:10.1542/peds.2021-050432
6. Colvin JD, Hall M, Berry JG, et al. Financial loss for inpatient care of Medicaid-insured children. JAMA Pediatr. 2016;170(11):1055-1062. doi:10.1001/jamapediatrics.2016.1639
7. VonAchen P, Gaur D, Wickremasinghe W, et al. Assessment of underpayment for inpatient care at children’s hospitals. JAMA Pediatr. 2021;175(9):972-974. doi:10.1001/jamapediatrics.2021.1133
8. Medicaid and CHIP Payment and Access Commission. MACStats: Medicaid and CHIP Data Book. Published February 2026.
9. Massachusetts Health Policy Commission. Consolidation and Closures in the Massachusetts Pediatric Health Care Market: Special Policy Report on Implications for Cost, Quality, Access, and Equity. Published September 2023.
10. Russ CM, et al. The pediatrician workforce in the United States and China. Pediatrics. 2023;151(6):e2022059143. doi:10.1542/peds.2022-059143

II. PICU Geography, Access, Transfer, Readiness, and Patient Harm

1. Horak RV, Griffin JF, Brown AM, et al. Growth and changing characteristics of pediatric intensive care, 2001-2016. Crit Care Med. 2019;47(8):1135-1142. doi:10.1097/CCM.0000000000003863
2. Bucholz EM, Day RT, Khazanchi R, et al. Geospatial accessibility of pediatric resources by Child Opportunity, racial and ethnic composition and urbanicity. Acad Pediatr. 2025;25(5):102817. doi:10.1016/j.acap.2025.102817
3. Cifra CL, Lin O, Gonzales CL, et al. Interfacility transfer and admission to PICUs in the United States: survey of referral communications in 2023. Pediatr Crit Care Med. 2025;26(5):e669-e679. doi:10.1097/PCC.0000000000003702
4. Ames SG, Davis BS, Marin JR, Fink EL, Olson LM, Gausche-Hill M, Kahn JM. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568. doi:10.1542/peds.2019-0568
5. Newgard CD, Lin A, Malveau S, et al. Emergency department pediatric readiness and short-term and long-term mortality among children receiving emergency care. JAMA Netw Open. 2023;6(1):e2250941. doi:10.1001/jamanetworkopen.2022.50941
6. Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. State and national estimates of the cost of emergency department pediatric readiness and lives saved. JAMA Netw Open. 2024;7(11):e2442154. doi:10.1001/jamanetworkopen.2024.42154
7. Remick KE, Foster AA, Jensen AR, et al. Pediatric readiness in the emergency department: technical report. Pediatrics. 2026;157(2):e2025075319. doi:10.1542/peds.2025-075319
8. Chien AT, Pandey A, Lu S. Pediatric hospital services within a one-hour drive: a national study. Pediatrics. 2020;146(5):e20201724. doi:10.1542/peds.2020-1724
9. Brown LE, França UL, McManus ML. Socioeconomic disadvantage and distance to pediatric critical care. Pediatr Crit Care Med. 2021;22(12):1033-1041. doi:10.1097/PCC.0000000000002807
10. Ramgopal S, Dubbaka S, Michelson KA. Trends in pediatric hospitalizations following interfacility transfer: 2009-2022. Pediatrics. 2026;158(2):e2025075267. doi:10.1542/peds.2025-075267
11. Schultz B, Mandt M. Pediatric and adult interfacility transports: a descriptive comparison. Pediatrics Open Science. 2025;1(2):1-9. doi:10.1542/pedsos.2024-000219
12. McDaniel CE, Hall M, Berry JG. Trends in distance traveled for common pediatric conditions for rural-residing children. JAMA Pediatr. 2024;178(1):80-81. doi:10.1001/jamapediatrics.2023.4945
13. França UL, McManus ML. Trends in regionalization of hospital care for common pediatric conditions. Pediatrics. 2018;141(1):e20171940. doi:10.1542/peds.2017-1940
14. Leyenaar JK, Freyleue SD, Arakelyan M, et al. Rural-urban disparities in hospital services and outcomes for children with medical complexity. JAMA Netw Open. 2024;7(9):e2435187. doi:10.1001/jamanetworkopen.2024.35187
15. Shinozaki RM, Schwingshackl A, Srivastava N, Grogan T, Kelly RB. Pediatric interfacility transport effects on mortality and length of stay. World J Pediatr. 2021;17(4):400-408. doi:10.1007/s12519-021-00445-w
16. Joseph AM, Horvat CM, Evans IV, Kuch BA, Kahn JM. Helicopter versus ground ambulance transport for interfacility transfer of critically ill children. Am J Emerg Med. 2022;61:44-51. doi:10.1016/j.ajem.2022.08.032
17. Newgard CD, Rakshe S, Salvi A, et al. Changes in emergency department pediatric readiness and mortality. JAMA Netw Open. 2024;7(7):e2422107. doi:10.1001/jamanetworkopen.2024.22107

III. Corporatization, Ownership, System Outcomes, and Clinician Effects

1. Ho V, Metcalfe L, Vu L, Short M, Morrow R. Annual spending per patient and quality in hospital-owned versus physician-owned organizations: an observational study. J Gen Intern Med. 2020;35(3):649-655. doi:10.1007/s11606-019-05312-z
2. Zhu JM, Hua LM, Polsky D. Private equity acquisitions of physician medical groups across specialties, 2013-2016. JAMA. 2020;323(7):663-665. doi:10.1001/jama.2019.21844
3. Kane CK. Physician Practice Characteristics in 2024: Private Practices Account for Less Than Half of Physicians in Most Specialties. American Medical Association; 2025.
4. Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365-2375. doi:10.1001/jama.2023.23147
5. Kannan S, Bruch JD, Zubizarreta JR, Stevens J, Song Z. Hospital staffing and patient outcomes after private equity acquisition. Ann Intern Med. 2025;178(11):1529-1538. doi:10.7326/ANNALS-24-03471
6. Cerullo M, Yang K, Joynt Maddox KE, McDevitt RC, Roberts JW, Offodile AC 2nd. Association between hospital private equity acquisition and outcomes of acute medical conditions among Medicare beneficiaries. JAMA Netw Open. 2022;5(4):e229581. doi:10.1001/jamanetworkopen.2022.9581
7. Kannan S, Song Z. Financial and clinical characteristics of hospitals targeted by private equity firms. JAMA Intern Med. 2024;184(10):1127-1129. doi:10.1001/jamainternmed.2024.3319
8. Physicians Advocacy Institute, Avalere Health. PAI-Avalere Study on Physician Employment/Practice Ownership Trends, 2019-2023. Physicians Advocacy Institute; April 2024.
9. Blumenthal D, Gumas ED, Shah A, Gunja MZ, Williams RD II. Mirror, Mirror 2024: A Portrait of the Failing US Health System. The Commonwealth Fund; September 19, 2024.
10. American Medical Association. Physician burnout rate continues to decline, falling to nearly 42% [news release]. Chicago, IL: American Medical Association; April 16, 2026.