NC Pediatric Society Winter Open Forum

To begin I have to thank Steve Shore and the executive committee for planning the Winter Open Forum within two blocks of a Starbucks (of course how hard would you have to work to find a conference location that isn’t within two blocks of a Starbucks?). Having started my drive from Wilmington to Charlotte at 5:00 AM, I was relieved to see the familiar mutant mermaid beckoning like a strip mall siren on Bruton Smith Blvd. On the horizon was the Embassy Suites, its glass-pyramid roof designed to make IM Pei cry.

Stoked on mocha I barely noticed it was 16 degrees out as I dashed across the parking lot into the warmth of the hotel conference center. Immediately I saw familiar faces from residency and the AAP, including our mastermind, Steve Shore. I grabbed a seat at the front and pulled out my camera, only to find the battery dead. I apologize for the cellphone photos that accompany this blog, but I needed some sort of visuals.

Steve Shore springs into action as our President Dr. Marian Earls opens the session.

As is our tradition we began by passing the microphone around the room so each of us could introduce ourselves. If the AAP ever takes this up we’ll have to schedule an extra couple of days. Naturally the turnout from the Charlotte area was good, but Shelby Pediatrics took the cake; apparently they rented a bus.

Brandon Rector, MSW

Brandon Rector, MSW, of the NC Immunization Branch hosted the first session. Here are the take-homes:

• Flu season is just now starting.
• Fluvirin, Flumist, Fluzone are all still available.
• Flumist expires shortly after shipping, so you may only have a month or a couple of weeks to use it upon receipt.
• Updates are coming out all the time, so pay attention.
• Boostrix can now be used up to age 18 years.
• NCIR is working better over the last two months but did have an outage last week related to password service. 
• Practices not yet on NCIR should be getting on soon.
• Plain HIB will not be back until mid-2009, when both Merck and Sanofi should be shipping again.
• There will be a lecture at the NC Pediatric Society State Conference August 12th to 16th, “Immunizations - The Real World, NC”
• For those with EMR a one way interface with NCIR is in beta testing.
• State flu vaccine can be given to anyone, including parents if you’re into that kind of liability.
• Private vaccine may be given side-by-side with state vaccine.
• H1N1 influenza is currently the dominant strain.

John Rusher, MD, JD

Next up was my residency classmate John Rusher speaking on reimbursement and legislative issues. I didn’t actually know John was a lawyer or I’d have been nicer to him. I guess I’m naive, but before John spoke I’d honestly never considered the impact of combination vaccines on administration fee revenues. Here are the bullets I got (not literally).

Reimbursement Issues

• Administration fees for vaccines within Medicaid increased to $17.21 for first vaccine + $9.71 for each additional vaccine.
• Unintended consequence of combination vaccines is a decrease in physician reimbursement.
• At least 70% of MD’s use combination vaccines. 30% are still ordering single antigen vaccines.
• NCPS has asked private insurers to increase reimbursements, although it’s not clear how they’ll respond.
• David Tayloe commented that Glaxo makes Pediarix so NC has an incentive to promote it. Humana will reimburse for combination vaccines with an additional $10. Texas Medicaid has also started reimbursing more. Not yet clear what NC Medicaid will do about this. Goldsboro Pediatrics may have to give up Pediarix for this reason.
• Tara Larson of NC Medicaid says they’re still looking at it.
• When the state calculates whether to purchase a combination vaccine they factor in the savings on administration fees.

Legislative Issues

• SCHIP reauthorization (NC Health Choice). State is waiting for Senate vote, since Feds cover 75% of this cost. May be signed in the next week or two by Obama.
• $2 Billion gap in state budget projected for 2009. Beverly Purdue is pushing the feds for $1 billion but will also cut $1 billion from the state budget.
• Compared to other states NC has excellent Medicaid reimbursement, an effort which will continue over the next year.
• Also pushing to protect/keep the state’s very successful vaccine program.
• Our reimbursement for sub-specialists is relatively poor in NC, and this contributes to a shortage here.
• Talk to any local legislators you know, also make the NCPS aware. Get on the Key Contact list.
• Participate in White Coat Wednesday at the State Legislature, occurring on four Wednesdays this spring.
• Statute of limitations for malpractice regarding infants is 19 years in NC; one practice was sued 3 days prior to expiration. We are working on that along with Medical Mutual.
• Please contact your state legislators and let them know you’re available to discuss pediatric issues. Also talk with Health Policy Advisor for Senators Hagan and Burr. Only takes 1-2 minutes, but matters.

Dr. Marian Earls, Deborah E. Carroll PhD, Vivian James

Next Dr. Marian Earls, Deborah E. Carroll PhD and Vivian James clarified how North Carolina is dealing with autism referrals. This topic is so big even three people talking very fast could only skim it.

• 2007 Recommendations: 
• Surveillance q visit. 
• Screen with MCHAT at 18, 24 months.
• Risk Factors (2/4): 
• Sibling with ASD
• parental concerns
• other caregiver concern
• pediatrician concerns
• If 2/4 risk factors present skip the screening and go to evaluation. 
• Evaluations should include Audiology Evaluation, ASD evaluation, Early Intervention Evaluation.
• Add Developmental and Behavioral Pediatrician, Geneticist, Neurologist PRN relevant concerns.
• Deborah Carroll expounded on what the CDSA will provide: 
• IFSP (Individualized Family Service Plan), 
• Early Intervention. Please alert CDSA as soon as possible.
• Department of Public Instruction: Vivian James. What do you do for a child who has turned three?
• Now releasing a flowsheet to describe how they (Preschool Exceptional Children Program) deal with referrals. 
• Trying to clarify what information pediatricians need to send with a referral. 
• Now have a form for two-way release of information.
• Working on training evaluators in diagnosis of autism.
• They need information up front: contact information, release of information form, vision/hearing screen, developmental screen, behavioral health screening.
• Idea is to increase consistency among the offices across the state.
• Health Department can expedite child service coordination.
• TEACCH is not so much for diagnosis as for management of autistic children in schools.

Tara R. Larson, Acting Director, Division of Medical Assistance 

Our next speaker was Tara R. Larson, on the topic of Psychological Testing for School Children. If you see Medicaid patients you might consider dropping Ms. Larson a little thank you note every time you pay your rent.

• It looks like SCHIP will survive, expand.
• CPT codes were updated in January to add codes for mental health, substance abuse screening and treatment.
• Trying to simplify Edits/Audits to reduce limitations on what can be billed on the same day. Can we do more in an office visit and provide multiple kinds of interventions/activities?
• Looking for: Depression, Anxiety, ADHD, Substance abuse, Learning Disabilities, Physical/sexual abuse, Autism.
• Check out www.icarenc.org for evidence-based tools.
• Parents are experiencing increases in depression and substance abuse, domestic violence.
• Domestic violence: screen all females age 14 or over.
• Only schools can bill Medicaid for educational assessment. Schools were given a loophole to the Free Care Rule (you can’t bill Medicaid if you don’t bill everyone). Schools may bill for evaluation that results in an IEP.
• Providers can bill ASQ, mental health and substance abuse screening provided along with E&M (there are some limitations on number or hours per day and should not be done in the hospital).
• Psychologists can be co-located with physicians.
• Mental health practitioners must have whatever supervision is required by their boards.
• Adolescent package: based on Bright Futures model. Not yet implemented, but going to physicians advisory board.
• National Provider Identifier required as of May 1, 2009.
• New Medicaid Management Information System has been contracted. Will require consultation with offices’ billing managers to implement.
• David Tayloe commented: agencies that provide services to exceptional children have financial disincentive to serving more children. Currently psychologic professionals cannot bill for evaluations that are requested by the schools.

Paul Miles, MD

Dr. Paul Miles next took the podium to clarify why maintenance of certification has become so complicated. He put the process in a historical context starting with the idea physicians should have some process to ensure basic competency and tracing the evolution of how we define competency. Apparently it’s no longer enough to pass a test once shortly after we graduate residency. Spoiler alert for those who were "grandfathered in": the NC Medical Board may require you to participate in Maintenance of Certification even if the American Board of Pediatrics doesn't.

• Medical knowledge was the first thing we could test, but it’s now clear knowledge alone is not enough.
• 1933: AAP founded.
• 1952: First randomized trial.
• 1975: First practice variation study
• Dartmouth Health Atlas: 
• Demonstrates variation in care using Medicare data. 
• Shows an inverse proportion between spending on care and outcomes. 
• Mayo is the model for implementing standards.
• 2000: Institute of Medicine Reports - the system does not revolve around delivering quality of care.
• You need to be able to measure and improve the quality of care you deliver. Not just the individual but the entire team must be involved. This is the idea behind the maintenance of certification process. Evolved from one test to a q 7 year test to a perpetual process.
• Improving access is great, but alone it won’t fix the problems in pediatrics. Controlling costs, improving quality are the other legs of the stool.
• “Trust me, I am a physician,” is no longer enough. The new age of transparency will require us to demonstrate our outcomes are adequate. What’s new is that we can define and improve quality of care.
• The Board of Pediatrics will have a major role in helping reduce the unexplained variations in quality of care.
• Adults get recommended care 54% of the time, children 46% of the time. (Mangione-Smith) Figures likely worse for children with barriers to care.
• Certification now includes four parts. The real roll-out is next year 2010.
• Over five years will need to acquire 100 points in practice improvement and continuing education. Every five years register and pay fee. Every ten years take maintenance of certification exam. Must have valid and unrestricted medical license.
• Subspecialists will have their own exams, but activities will count toward whatever.
• Website will tell you what part 2 and part 4 activities you have to complete.
• The nice thing is exam dates will be extended an extra three years.
• If you have a permanent certificate you may voluntarily participate in the maintenance of certification program. Start by passing the test, then you enter the five year cycle. If you wait until 2010 you must pass the test and acquire your 100 points over two years instead of five years. Results will be posted on the Internet. There is a rumor the State Licensing Board of NC may require maintenance of certification even for permanent certificate holders (Chuck Willson).
• Part I: Professionalism in Practice. Valid, unrestricted medical license. Disciplinary Action Notification System.
• Part II: Lifelong Learning & Self-Assessment. Multiple choice questions based on PREP program. There is a menu of activities you may participate in.
• Part III: Cognitive Expertise. Secure Exam Every 10 Years
• Part IV: ABP approved quality improvement projects. May participate in web-based modules (nutrition module available on AAP website). Another module on Patient Safety is available to all physicians, not just pediatricians. IPIP (Improving Performance In Practice) gives 20 points and may contribute almost all 100 points over five years. Also AAP EQIPP modules available.
• Example is Reducing Catheter-Associated Bloodstream Infections to Zero. Has prevented 65 deaths, 600 infections, saved $12 million.
• At onset of IPIP 3% of kids were getting “perfect” asthma care. After two years went up to 88%. Initially the physicians paid to participate. Then they negotiated to be paid, and some people really stepped it up.
• North Carolina Health Quality Alliance. About half the time interventions we all agree should happen don’t regardless of problem or setting. Everyone collects exactly the same data so it can be compared across practices and regions. Starting in Eastern and Western NC and then spreading it across the state.
• When group provided perfect care, they had a 50% drop in admissions for asthma, a 40% drop in ED visits.
• IPIP provides tools, help establishing a database, comparisons and fellowship with other practices, CME and MOC Part 4 credit, some financial support, access to national leadership in quality improvement.
• IPIP expects you to form a team, participate in dinner meetings, analyze data, commit to changing practice systematically, testing whether changes worked, meet with coaches.
• www.abp.org will tell you what you need to do.

Dr. Miles's point was best summed up by the above Margaret Bourke-White Depression-era photo. We have some of the best health care in the world, but we don't make it uniformly available.

Lanier Cansler, Secretary of the NC Department of Health & Human Services

I have to plead great ignorance to the subtle (or even obvious) aspects of state politics as they impact pediatric practice in North Carolina. But the people at the meeting who weren't so ignorant seemed very, very happy to welcome Lanier Cansler. The following of his statements got my attention.

• The state is trying to cut 7% from Medicaid overall.
• Hoping to find ways to cut budget without an across-the-board cut in reimbursements. They would prefer to accomplish this by improving preventive care, chronic disease management.
• They would very much appreciate physicians' contributions to this effort.
• Best thing that could happen here is for the Senate version of the SCHIP bill to include funds for NC Kids Care.

Next we heard a brief update from the chairs of all the major pediatric referral centers here in North Carolina. I have to apologize for my sketchy notes here. These people talked fast, at times overwhelming my typing skills.

Dale Newton, update from ECU

• Just opened cardiac medicine unit.
  
• Pediatric cardiology offices have moved, but inpatient services remain in children’s hospital. Plan is to add 100 beds total to the hospital, including new pediatric ED.

Carolinas Medical Center Charlotte. 

• 14 months into new pediatric hospital.
• Recruited tons of specialists.
• Opened three satellites.
• Holding Pediatric Board Review Course in May in Charlotte.
• Developing a quality improvement curriculum for residents.

Clemmons, Duke

• 13 bed pediatric cardiac intensive care unit, now full.
• New pediatric echocardiography facility.
• New Pediatric Obesity fellowship 2-year program.

Alan Stiles, UNC

• Deaths of several pioneering staff, ending with Rebecca Soccolar.
• New director of bone marrow transplant.
• Raleigh clinic open and seeing patients.
• New ICU space being built.
• Trying to get services to patients.
• Starting newborn screening for cystic fibrosis (George Retsch-Bogart)

Following was an open discussion on whether anyone will continue going to cesarean deliveries. Rural practices cannot recruit new physicians when this requirement is in place.

 

Dr. David Tayloe, President, American Academy of Pediatrics

Our next speaker was David Tayloe, currently on loan to the Academy from North Carolina. The AAP has been instructed to return him to North Carolina after a year with no new scratches or dents. Dr. Tayloe challenged us with a profound question I have to confess I hadn't given any thought to: if neonatologists, critical care specialists, and hospitalists take over our hospital duties, pediatric specialists manage our complex patients, and retail-based clinics see all the ear infections, is there any role left for general pediatricians? Below is my best effort to summarize his points.

• Strategic planning committee working on Vision of Pediatrics 2020
  
• Looking at Access, Quality, Payment
  
• Medicaid, SCHIP, Vaccines for Children, MediKids, Health Care Reform are all key to our reimbursement.
  
• New bill includes Medicaid Payment Advisory Commission to report to Congress on payment issues, which Medicare has always had. This is “huge.” Talk to your senator to push this. Will have to go to conference, and this will be controversial. Also the inclusion of children of legal immigrants is locked out for five years now, which is unconscionable.
  
• Trying to improve the Vaccines For Children Program to make other states as good as NC.
  
• Pushing MediKids as a safety net for uninsured children who fall in the gap between Medicaid and private insurance. Would include graduated premiums.
  
• Quality - Chapter Alliance for Quality Improvement. EQIPP program on asthma, ADHD, Nutrition/Obesity. Patient Centered-Primary Care Collaborative and National Committee for Quality Assurance. These associations are designed to save corporations money by making sure patients have a patient-centered medical home.
  
• Payment: Equal Access Clause of OBRA 89. Try to make sure MediKids doesn’t move children from private insurance to a lower-paying version of Medicare. Medicaid payment should mirror payment of private insurance to make sure access to care is fair in a given market. 
• Generalist and specialist income: how do we address the special issues affecting high-cost special needs children?
  
• Community pediatrics: our job is shrinking, taken up by retail based clinics, neonatologists, and hospitalitst. Need to make sure something is left of general pediatrics. 
• We’re the only country where pediatricians are front-line for children’s primary care. In other countries generalists and mid-level practitioners are the front line.
  
• How are we going to get care into rural areas? Can the academic centers do this job?
  
• Can debt relief help bring more people to general pediatrics?
  
• Health Equity. How do we address poverty, language barriers?
  
• Immunization Alliance - stop the autism craziness. DAN (can they be brought into best medical evidence?). Restore public trust in immunizations.
  
• Mental Health - Jane Foy is working on this.
  
• Foster care - we have a White Paper and a manual from the Academy for guidance on caring for these children.
  

I have to apologize to Dr. Marian Earls, Dr. Jennifer Lail, and Dr. Gerri Mattson for failing to photograph their presentation. I got to typing so fast I never picked up my phone, unlocked the keys, toggled to camera, hit "take photo," and snapped their pictures. I have to admit here, I tend to get droopy eyelids whenever I see the words "Medical Home." What's the big deal? But as these three spoke my eyes grew wide. Medical Home means improved quality of care, more efficient visits with the most challenging patients we have, and maybe even more reimbursement. I'm awake! See if you can follow this.

Dr. Earls

• Can we get some sort of payment for being a medical home?
  
• Risk Stratification: psychosocial risks can predict IQ. High risk kids underperform low risk kids on ASQ, worse by increasing age.
  
• SHEPHERD Index looks at child and parent psychosocial risks. Strong predictor of low reading, low math, behavior problems.
  
• Registering complexity coding sheet, ICD-9 codes, claims from CMIS.
  
• Risk factor scale includes medical risk factors, child’s family risk factors, agency involvement, ethnic background, CP, Autism, CF, MD, etc. Includes parent with non-English speaking caregiver, psychologically or medically disabled parents, teenaged parents, parent with >3 children.
  
• Registry allows practice to list these kids, make sure they’re getting adequate follow up care. Can look at each risk factor to see where the needs are.
  
• If you know you have a large number of patients with a specific condition you can create a pathway for that condition.
  

Dr. Lail

• Pilot program looking at children with special healthcare needs in suburban private practice with 2 offices, 12 MD’s (9 full time equivalents). 22% are self-pay. 
• Registry is the “left ventricle” of the medical home. 
• Complexity scores help get children proper appointment times. Can help staff plan for visits, connect families together based on diagnosis. Clinic calls family in advance to assess parental concerns. Care coordinator makes sure all the information needed for the visit is actually in the chart when the patient arrives. Includes gathering information from specialists, studies.
• Transitioning: find a “champion” to create the registry. Link registry to appointment scheduling. Start by asking providers which children always are special needs. 

Dr. Mattson: Planning for Transition With Youth With Special Health Care Needs

• Identify your special needs patients when they’re around age 12 and start planning at that point for transition.
  
• Shift health care responsibilities to patient when possible.
  
• Involve specialists, adult providers, family, and other support systems.
  
• Carolina Health And Transition Project. Will provide a web-based toolkit. 
• Start with Portable Medical Summaries. Also Emergency Information Forms. Then Transition Readiness Checklists, Transition Action Plan, Welless Baselines, Health Insurance Resources. 
• Can patient understand and explain needs, carry insurance card, call for refills, carry emergency information?
  
• Identify 1-2 skills to work on, agree on a plan, identify timeframe to accomplish the plan, agree on a future date to assess progress/update plans.
  
• Baseline report goes by body system to report whether something is going worse or better, whether needs are present. Can be used to plan for the visit ahead of time.
  
• What is your office age limit? Need to establish a policy.
  
• Do you have a special transition visit?
  
• Can you build a relationship with an adult provider in the community to aid with transitioning?
  
• Code based on time, because it will take a lot of time. Reimbursement will be most appropriate this way. Be sure to include discussion of duration, specific tools. May use prolonged service codes in addition to E&M code.
  
• Send letter to adult providers: are you accepting new patients? How should the new patient access the practice? Which providers are most interested in seeing these patients?

Finally we turned in our CME sheets and course evaluations, piled into our cars, and returned to the far corners of the state, our heads full of new ideas. It took about 45 minutes to drive a mile back to the I85 onramp due to holiday traffic. If you're passing through Monroe, NC may I recommend the Target, which has a Starbucks inside it! If that's not retail heaven I don't know what is.

Schedule permitting I'll try to do this again April 4th at the Spring Open Forum at the Research Triangle Park Hilton. I'll bring a charged camera.