NCPS Spring Open Forum 2009

There are all sorts of places one might spend a perfect spring Saturday morning: the beach, the back yard, a dimly lit Hilton conference room in Durham. I chose that last one, since that's where the North Carolina Pediatric Society's Spring Open Forum was being held. Several dozen of our pediatric colleagues from around the state made the same choice, which seemed the least we could do given all the work Steve Shore and Marian Earls put into the agenda. The program was so good in fact I started to feel sorry for all my colleagues on their boats or on the sidelines of their children's soccer games. So I snapped a few pictures and took some notes so you wouldn't feel like you'd missed too much.

Opening: Dr. Marian Earls, FAAP, President of the North Carolina Pediatric Society

Pass around the microhone, introductions. Weirdest coincidence: almost everyone there was a pediatrician!

Thanks to Laura Buxenbaum, our host from sponsor Southeast United Dairy Industry Association. Got milk? We did, in abundance. Also pastries, fruit, and coffee.

 Brandon Rector, MSW, Immunization Branch

• Stimulus package may direct some money toward influenza vaccines in schools, NCIR rollout to all providers.
  
• Six competitive grants for stimulus money, but not sure for what.
  
• Immunization rates have been falling in NC and nationwide.
  
• Hib shortage: still do three doses ActHib, 2 doses Pedvax.
  
• Reminder recall is part of the NCIR, look to see who is behind and call parents to bring them back in.
  
• Do we want the state to start finding children who are behind and reminding their parents to get them in. Medical, parental choice, and religious exemptions are coded in the registry.
  
• Larry King Live had an episode last night with Jenny McCarthy again.
  
• Alternative schedules: you are supposed to use the ACIP schedule as the standard if you’re part of the state program, but you are not prohibited from using an alternate schedule at parents’ insistence.
  
• McKesson is now contractually obligated to ship vaccines within three to five shipping days (Monday through Wednesday) and it takes the state one day to transmit your order to McKesson. If you order on a Thursday that means you’re looking at a week before they’re ready to ship.
  
• US and European vaccines are manufactured to the same standards.
  
• HBV vaccine supplies are variable right now, may see some supply interruptions but so far we have enough to get through May. No schedule changes at this time.
  
• State is working toward a universal vaccine program in North Carolina.
  
• Some practices in Mecklenburg County are working on a two-way NCIR interface.
  
• Several doctors brought up concerns that if schools perform influenza vaccines they may not enter them into the NCIR in a timely fashion. Can the state inform physicians when their patients have received the influenza vaccine?
  

 John Rusher, MD, JD, FAAP with legislative update.

Representative Jennifer Weiss from Wake County here to receive Presentation of Excellence in Public Service Award.

Jennifer Weiss: 

• Hard to get safety bills passed due to sentiment people should make their own choices. Pediatricians need to keep pressing legislators to get these bills passed.
  
• Legislative priorities from John Rusher:
  
• Get coverage for universal vaccination program from the state legislature. Seems like funding may hold steady or even increase.
  
• SCHIP/NC Health Choice. Federal matching funds will come to NC to cover children's healthcare in families up to 200% of the poverty line. Probably will not need to have a waiting list for families to join. Kid's Care, which should cover children up to 300% of poverty line, is likely not going to happen.
  
• Medicaid reimbursement should remain at 95% of Medicare, which makes ours one of the best states in the nation for Medicaid reimbursement.

We have 25 bills of interest pending in the NC Legislature. Some highlights:

• House Bill 2: Prohibit smoking in public places. Amendments are filtering this bill, but it is headed to the Senate. Latest amendment for businesses that don't admit minors.
• House Bill 88: Healthy Youth Act. Provides choice of abstinence or more accurate comprehensive sex education program. Most parents chose the more comprehensive program, even in New Hanover County.
• House Bill 523: Increasing folic acid supplementations to prevent neural tube defects.
• Several bills to improve school cafeteria foods and reduce presence of vending machines.
• Senate Bill to ban texting while driving and teenage mobile phone use while driving.
• Senate Bills to implement Child Fatality Task Force findings to reduce shaken baby, SIDS, mainly funding educational programs.
• S699: Cement plant moratorium and study. I got to give a three-minute summary of the Titan issue.
• Budget continues to shrink as economic predictions catch up with current conditions. Unemployment may go as high as 14% in North Carolina ultimately.
  
• Please participate in Pediatric White Coat Wednesdays April 22, May 20, and June 10th. Or call John Rusher and he'll get you in any day of the week.
  

 

Tara Larson, Division of Medical Assistance

• New Medicaid Director is Dr. Craigan Gray, MD, MBA, JD. Has practiced as an OB/Gyn in Asheville.
  
• Federal Matching Funds (FMAP) will be around 74% of the State's outlay, which is enough to cover the Medicaid budget as certified. This is a big deal, since we thought we might run over budget by $200 million.
  
• Governor's budget was good news. Senate's budget is being released next week, some rate reductions expected in physician payment. Senate is looking to bring NC Medicaid closer to the less well-paying programs in other states, but we argue that will just increase ER use and waste money rather than save it.
  
• Health Information Technology funds: still organizing in the state; feds have not specified what the qualifications will be to get our hands on those funds. Hope to fund electronic records, exchange of information between providers.
  
• Also should be able to pay hospitals more federal dollars for providing indigent care to the uninsured (DISH). The cap is going up on those funds. Additional $200 million.
  
• NC is one of the 16 states the Government Accounting Office will be monitoring for use of recovery money. This means lots of documentation and accountability, lots of red tape for the State.
  
• Medicaid is auditing personal care services, use of preferred drugs, utilization of hospitals, specialized therapies (OT, PT, Speech, Audiology) to make sure usage is appropriate and care is coordinated with medical home.
  
• Formulary is currently open, but a preferred drug list may be on the way, especially if we run short of money in Medicaid.
  
• Computer Service Corporation is our new vendor for Medicaid payment processing and provider enrollment. They will start doing the processing of applications, and all of this will be online. Turn-around time from application to approval should go from 12 weeks to 10 days.
  
• Will be reviewing all existing providers, re-credentialling. Don't worry, you won't have to submit new applications or change provider numbers.
  
• National Provider Identifiers must be in place by May 1st. If you don't use it, claims will be denied.
  
• UNCOLA: not Sprite. This is the Cost of Living Increase, which impacts the Federal Poverty Level. Sometimes people lose Medicaid eligibility or suddenly have deductibles in place of full eligibility. About 9000 Medicaid recipients will be affected this year, mostly adults and older teens.
  

NC Health Choice:

• We may reach our cap of 6% and have to put a hold on new enrollment.
• Kid's Care just isn't going to happen.

New Medicaid billing guide released April 1st:

• Now paying annual visits from ages 2 to 20 instead of q 3 years.
• New coverage for autism services, paying for MCHAT testing on the same day as a wellness exam.
• New payment for mental health screening.
• New Adolescent Package will expand coverage for teen care, may go into effect 7/01/2009.
  
• New waiver for people with traumatic brain injury to get Medicaid coverage, being introduced in the legislature, not yet approved.
  
• Applied Behavior Analysis may be covered as autism therapy.
  

Gerri Mattson, MD, MSPH, FAAP, Dr. George Retsch-Bogart MD, & Alice Lenihan, MPH, RD, LDN on NC Divison of Public Health

Gerri Mattson: expanding Newborn Cystic Fibrosis Screening; NC will be second-to-last in the nation to add this (Texas will be last). 

• First test is IRT (immunoreactive trypsinogen) level, then if 95%ile follow up with DNA testing.
  
• Report will be sent to provider.
• If screen is abnormal then patient should have sweat chloride testing at an accredited center (there are 6 available).
• There is a follow up coordinator to make sure these kids get followed up.

Dr. George Retsch-Bogart reviewed two-tiered screening plan and the research and data that led to current plan. The testing is going to also identify infants who are carriers.

• Abnormal results will be called, faxed, and mailed.
  
• Results will not be available on line.
  
• Sweat chloride testing should only be done at CF Care Centers.
  
• Newborns with two mutations have a higher probability of CF.
  
• CF Foundation information will be available for providers and families.

Changes in WIC program, Alice Lenihan:

• Moving away from whole milk for every child over age 12 months.
• State does not have enough funds to purchase enough vitamin D for everyone. Only providing it for infants who are exclusively breastfed.
• Will need to write prescriptions for fruits, vegetables through WIC if children are on exempt or specialty formula products.Will be able to prescribe tofu in place of milk products. This is for cultural or religious reasons.

Open Information Session by Steve Shore:

Dr. Francis Rushton, President District IV with District Update

• Please vote in district and national elections.
• We have a new logo for the AAP. This is a way to visualize our priorities. Increased focus on health equity. Adding a new issue, early brain development.
• Academy's financial status not so good. Looking at a $1.8 million deficit. This is around 2% of the budget.
• No draconian budget cuts are planned.
• Healthcare reform is big on our agenda, and the Obama budget looks like it may lead to increased payments for primary care providers. David Tayloe is strong on this subject.
• The AAP is seeing a decline in subscription renewals and publication purchases. Dues coming up soon, hard to know how it's going to go.
• Please remember all the professional value your AAP membership offers you.

Frank Loda, MD, Presenting the Purple Project

• PURPLE crying DVD given in the hospital, this is the first dose.
• At first follow up visit we should give parents a reminder, and give the the DVD if they haven't already watched it. This is the second dose.
• Third dose is working with community groups to support their work on educating parents.

Dr. Paul Harrison, Wake County Medical Society on NCIR Patient Recall

• Wake County Medical Society: Urged to use NCIR recall function. They can upload our data from anyone age 9 and over to utilize this to generate data on people who need immunizations. 
• We have to sign a HIPAA compliance statement. 
  
• Must provide four pieces of data: patient's name, parent's name, address, date of birth.
  

Dr. Lorrie Hicks

• Pediatric palliative care coalition of NC
• Seek to educate health care professionals and families.
• Working on policy changes at the legislative level. Children on home health care cannot also receive palliative care benefits.
• Resource for families and physicians throughout the state.
• There will be a meeting in Raleigh, April 28th if you're interested in this topic.

Department Chair Reports

• Duke, Joe St. Jeme. Good match results, lots of new faculty in many divisions. New Cardiac ICU open. New echo lab open. New campus in Wake County for specialty practice. Communications Task Force working on communicating with referring pediatricians.
• Julie Byerley, UNC. US News & World Report ranked the pediatrics program #22 in the nation. We plan to be ranked even higher. Great match results. Also working on Raleigh clinics for specialty care. New airway team with a center focusing on airway issues, tracheostomy care.
• Dale Newton, ECU. State budget cuts continue to climb from 2% to 10%, but fortunately only 25% of the budget comes from the state. Bad news is uninsured patient burden continues to rise. Great match results this year.
• Mike Lawless, Wake Forest. Hosting a Practical Pediatrics course in two weekends. Felt good about match results.

 

Lieutenant Colonel Barbara L. Bowsher, MD, FAAP, Chief of Pediatrics, Womack Army Hospital, Ft. Bragg

• What is it like to live on a military base? Supportive, everyone understands.
• Families have to move often, sometimes every year. A few can stay in one place for prolonged periods although this can be a detriment to promotion.
• Kids have to start over all the time, get used to new cultures, new friends. Kids lose their familiar routines.
• Moving doesn't happen at any predictable time of year. School changes occur randomly, and kids may lose academic credits with each move.
• Children transferring from Junior to Senior High School have an especially tough time. Also children moving from their Junior to Senior years in high school.
• Athletes may lose their rankings or even their entire sport.
• May go from a small school to a large school.
• Even if you stay your friends are always leaving.
• For parents deployments are now much longer than they used to be, often 15 months.
• Special challenges face families with only one parent or with two military parents. May be discharged if can't arrange child care.
• Reserve military are now being treated just like regular military, often very far from home. They do then get active duty benefits, which help the family.
• After deployment National Guard/Reserve soldiers have to re-create their old lives. Often require psychiatric services.
• Pre-deployment phase: lots of frustration, surprise. Families may move back to hometown.
• Deployment: often lots of community support. Family left behind have to do it all, including dad's job (or mom's job). Kids worry a lot about parents' safety. Kids have new responsibilities.
• Post-deployment: everyone has changed, everyone has a new routine. Kids have grown, developed, changed. Starts with a honeymoon phase, about 6 months. Then whatever marital issues were there before are still there. PTSD and traumatic brain injuries have a big impact. Returning soldier feels isolated.
• 1.2 million children are involved in military families. 700,000 kids in reserve/guard.
• NC is among the top states in the nation in terms of injured military personnel.
• Strengths: patriotism, sense of community, schools and community centers, travel.
• Research in mental health issues is rapidly expanding.
• Teens with deployed parents have increased HR and BP.
• Risk of physical abuse goes up when parents return from deployment.
• Up to 35% of returning soldiers need mental health services in the first year.
• HEADS exam: home, education, activities, depression, sex/drugs/alcohol.
• Kids may present with psychosomatic complaints.
• Parents may be in denial about how hard this is for the kids.
• What do they want? First listen to them. Try to understand.
• Resources: handouts from military, family readiness groups, on-base social workers, family advocacy program, army community services, primary care manager.
• Find someone else in the community teens/kids can talk to.
• Facilitate communication with deployed parent.
• Ask how the parent is doing during the child's visit. Let them know they'll see changes in their children.
• Look for Military OneSource to find resources.

Holly Haines, MD, Wake Forest University School of Medicine on Bisphenol A

• Started with alarmist news clips about BPA.
• Rachel Carson's Silent Spring demonstrated that very low doses of chemicals in the environment can have profound effects in certain combinations and at certain vulnerable periods of development.
• Studies in the Great Lakes in 1988 demonstrated endocrine disruptions in the offspring of certain birds exposed t environmental chemicals. Coined the term "endocrine disruptor."
• BPA is an estrogen agonist that helps make polycarbonate plastic. Terribly useful: clear, shatter resistant, heat-resistant.
• Also critical for epoxy resins that line food cans, bottle tops, and water pipes. Great for preventing corrosion, very flexible.
• 7 billion pounds of BPA are produced worldwide, one of the most widely used commercial chemicals today.
• BPA can be found in food, water, dust, air.
• The chemical bonds are unstable, releasing BPA into fluids. More rapid release with heat, washing, acidic or basic fluids.
• BPA is hydrophobic, so dissolves better in milk than in water.
• Leaching rate increases 55-fold with boiling water, continues to leach after exposure to heat at an increased rate.
• Highest leaching rates are in the very foods we're most likely to feed toddlers.
• 93% of NHANES participants had BPA in their urine. Highest levels are in children.
• So how much exposure is too much? EPA based threshold on animal experiments. That reference dose is 50 micrograms per kg per day. Safety dose has not been updated since the 1980's, and the true safe dose has never been defined.
• Toxic Substances Control Act passed in 1976 declared that all existing chemicals at the time were safe. The EPA would have to prove the chemicals do harm in order to regulate them.
• Levels of 2 to 20 mcg/kg/day cause reproductive abnormalities in mice in a 1997 study.
• With endocrine receptors you cannot presume a linear dose-response curve to any given chemical. There may be a threshold or even a "U" shaped curve. No one knows what that curve looks like for BPA.
• 2002 EPA announced it would not include low dose considerations in testing and screening protocols for endocrine disruptors.
• 81% of studies on low-level BPA exposure have demonstrated significant effects.
• Human studies published 9/2008 in JAMA. Mean BPA level correlated with DM and CAD. Causality could no be determined.
• FDA now admits significant concern about the effects of low-dose BPA on humans. FDA subcommittee in October, 2008 determined current levels defined as adequate are not.
• American Chemistry Council contends no risk to human health, "...making our lives safer, healthier, and easier."
• Retailers and manufacturers starting to withdraw BPA-based baby bottles and children's products.
• What can we do? encourage nursing, use BPA-free bottles, avoid canned liquid formula especially, avoid #7 plastic bottles.
• Not the same as phthalates, which make PVC products more flexible. They are also endocrine disruptors in utero in early development. May be associated with rhinitis, eczema, asthma.