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Dear Karen,
This is an excellent question. While I cannot comment specifically on the situation you mention, I can tell you that the Commonwealth of Virginia has a lengthy set of rules that governs the care of neonates, and specifies levels of NICU care. Much of that revolves around access to pediatric sub-specialists as you mentioned, such as pediatric pulmonary, GI, genetics, and surgery, among others. In addition, it specifies the minimum number of beds that should be in a NICU to allow reasonable access to those specialists. If you don't have a large enough patient population, you cannot attract those pediatric specialists. In addition, the regulations specify other services that must be available for certain levels of care. There are many hospitals throughout our state that have lower level NICUs without the variety of sub-specialists available. Those lower level NICUs or special care units can provide care for infants born at a certain gestational age, and with a certain number of limited medical problems. Any infants requiring a higher level of care must be transferred to another center where the care is available. One nearby example of what is known as a "level II NICU" is the NICU at Centra Health in Lynchburg. Neonates there who require surgery or sub-specialty care must be transferred to Carilion or to UVA, but many of the bigger premies are cared for there without a problem. The health commissioner is bound by the regulations in making decisions regarding whether or not to allow a new NICU to be created. She has to take into account the impact on any currently operating NICU in the area. For example, any existing NICU has to be quite full much of the time, in order to justify the creation of a new unit.

You are very perceptive in asking questions about the access to sub-specialists. This is a problem that all of the Children's Hospitals in Virginia are struggling with right now. Those include Inova Fairfax in Northern Virginia, Children's Hospital of the King's Daughters in the Southeast, VCU-Richmond Children's Hospital, UVA Children's Hospital, and Carilion Clinic Children's Hospital. There are not enough of these sub-specialists to meet the demand, and we are considering trying to share some of the ones in shortest supply. Supporting them requires having a certain number of patients so that a hospital can have more than one (not even the most dedicated doctor wants to be on call every night), and recruit the best available. Because of the extensive training they have undergone, they are typically more expensive to hire than general pediatricians, but because their patients are so complex, they spend more time with them during a visit, and therefore collect less total money from insurance companies than general pediatricians, as they see fewer total patients in a day, a week or a year. That is why most general hospitals never get to the point of wanting to have a comprehensive children's center. It is simply too expensive.

We are fortunate to have a wide variety of subspecialists at CCCH, and I am grateful that this allows us to keep children like your son in the region. Otherwise, children requiring sub-specialty pediatric care would routinely have to travel to Charlottesville, Winston-Salem, Richmond or Durham for excellent care. Sometimes that is still necessary for some very rare or complex conditions.

I hope I have addressed your question adequately. If not, I would be happy to have an off-line conversation any time. Just let me know, and thanks again, for stopping by.

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