DECEMBER 2008

BACKGROUND

This report has been funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of Services for Children with Special Health Care Needs. Recommendations in the report were developed by The Expert Work Group on Pediatric Subspecialty Capacity, which was established in 2004 to develop strategies to improve access to pediatric subspecialty care in coordination with a comprehensive, community-based medical home. Its members are affiliated with the American Academy of Pediatrics, the Child Health Corporation of America, Family Voices, the National Association of Children’s Hospitals, Shriners Hospitals, the Association of American Medical Colleges, Federal and State governmental agencies, and various academic and health policy institutes. The Maternal and Child Health Policy Research Center, in Washington, DC, provided staff support to The Expert Work Group. The views, opinions, and content of this document are those of The Expert Work Group and do not necessarily reflect the views or policies of the members’ organizations, the Health Resources and Services Administration, or the U.S. Department of Health and Human Services.

RECOMMENDATIONS FOR IMPROVING ACCESS TO PEDIATRIC SUBSPECIALTY CARE THROUGH THE MEDICAL HOME

The Expert Work Group on Pediatric Subspecialty Capacity has, since 2004, examined the current problems with pediatric subspecialty capacity in the United States and identified numerous innovative efforts for improving access to subspecialty pediatric care. Based on extensive deliberations, a vision and numerous practical strategies were developed for improving access to pediatric subspecialty care within the context of a comprehensive, community-based medical home. These recommendations are intended for use by a broad audience, including Congress, Federal and State agencies, national medical organizations, academic medical institutions, family advocacy groups, and health services researchers.

VISION

All children, adolescents, and young adults should receive high quality, comprehensive care through a medical home that assures timely access to necessary subspecialty care and facilitates the transition to adult care when appropriate.

STATEMENT OF PRINCIPLES

1. The medical home promotes well-coordinated partnerships among the family, primary care provider, pediatric subspecialists, other pediatric care providers, and related child-serving systems and has been endorsed by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians.

2. A sufficient number of pediatric subspecialists should exist to provide high quality tertiary care to children.

3. Full and equitable financing by third party payers and public health systems should be available to support the early identification and management of chronic conditions, comprehensive preventive care, and collaborative arrangements between primary and subspecialty pediatric care.

PROBLEM AND CAUSES

Access to pediatric subspecialty care is a crisis in the United States. There are five main causes of the access problem: 1) an insufficient number of pediatric subspecialists; 2) dramatically increasing demand for pediatric subspecialty care; 3) a fragmented and inefficient system of pediatric primary and specialty pediatric care; 4) inadequate financing of medical education; and 5) poorly structured payment mechanisms that are not well aligned to support pediatric subspecialty collaboration within the medical home model of care.

CONSEQUENCES

Diminished access to pediatric subspecialty care harms children and their families and creates costly inefficiencies for the health care system. The impact on children and their families are numerous and include: foregone care and adverse health consequences as a result of lengthy wait times for appointments and delays in obtaining diagnosis and intervention; compromised patient safety as a result of missed communications among providers and families; lower quality of care because of lack of collaboration and inability to sustain interdisciplinary teams; increased child and family stress and anxiety and provider dissatisfaction; and lost work and school time.

There are also serious consequences for the health care system: costs are higher than necessary due to reliance on emergency room services; expensive services are duplicated; pediatric services at children’s hospitals may be terminated as a result of recruitment and retention problems; and training of health care professionals who care for children, adolescents, and young adults suffers.

GOALS AND ACTION STEPS

1. Increase professional and public awareness of the medical home concept and the unmet needs that children have for pediatric subspecialty care.

A. Promote access to pediatric subspecialty care as a cornerstone of medical home reform efforts.

B. Develop a strategic educational campaign tailored to particular audiences -- families and advocacy groups, national medical organizations, academic training programs, providers, residents and fellows, payers, employers, Congress, governors and State legislators, and Federal and State agencies.

C. Create a clearinghouse of innovative approaches for improving pediatric subspecialty access through the medical home.

2. Increase collaborative arrangements among primary and specialty systems of pediatric care at the local, State, and regional levels in order to improve health care outcomes for children, adolescents, and young adults.

A. Significantly expand collaboration and consultation arrangements among academic medical centers, hospitals specializing in the care of children, primary care providers, and families.

B. Encourage interdisciplinary team care and effective interaction with pediatric subspecialists at the primary care level to facilitate collaborative patient- and family-centered care.

C. Expand the availability of care coordination mechanisms at both the primary and the subspecialty care levels.

D. Make available to primary care providers standardized tools for risk assessment, diagnosis, referral, and care planning for commonly occurring conditions, based on evidence-based research and taking into account primary care providers’ capacity and interest.

E. Expand the use of electronic medical records, telemedicine, and other information technologies to further the interface between primary and specialty care.

F. Increase the leadership role of State agencies, including Title V, in building collaborative arrangements between academic medical centers and pediatric subspecialists, medical home providers, and families.

G. Strengthen collaboration between pediatric and adult subspecialists in the care of children with special needs.

3. Enhance the training and practice of health care professionals to enable them to better manage the care of children with chronic conditions and work collaboratively with pediatric subspecialists within the medical home model of care.

A. Increase training of primary care providers and pediatric subspecialists in behavioral, developmental, and emotional issues; transition to adult care; and the medical home model of care.

B. Using Maintenance of Certification, coordinate continuing medical education activities on targeted specialty topics, such as mental health.

C. Expand pediatric residency outpatient electives and fellowship outpatient training requirements to ensure more training in consultation, referral, care coordination, transition to adult care, and other medical home concepts.

D. Offer more interactive continuing medical education for primary care providers and pediatric subspecialists, including opportunities for subspecialists seeing patients in primary care practices.

4. Ensure a sufficient supply of pediatric subspecialists to meet the needs of children requiring subspecialty care in coordination with the medical home.

A. Establish a national recruitment and retention strategy for pediatric medical and surgical subspecialties, working with academic medical institutions, specialty societies, national medical organizations, foundations, and government agencies.

B. Expand integrated pediatric and psychiatric graduate medical education tracks and explore the feasibility of other combined residency programs.

C. Explore the feasibility of shorter subspecialty training options for those interested in entering community practice rather than academic medicine.

5. Improve public and private financing mechanisms to ensure access to pediatric subspecialty care within medical homes, including appropriate reimbursement of collaborative and interdisciplinary care and graduate and continuing medical education.

A. Lift the graduate medical education caps for all physician subspecialties and increase support for graduate medical education to the 100 percent full-time equivalent (FTE) level for those residents training in a program after they completed an initial residency, not at the current 50 percent FTE level. Also, create new funding directed at pediatric subspecialties experiencing difficulties filling positions.

B. Create new training grants, scholarships, loan forgiveness plans, and tax incentives for pediatric medical and surgical subspecialties and for primary care providers seeking to increase their skills in managing chronic childhood conditions.

C. Support the establishment of a Medicaid Payment Advisory Commission to address physician reimbursement issues, including payment reforms to support the medical home model of care and also to address effective strategies for increasing participation in Medicaid.

D. Promote the availability of adequate public and private health insurance reimbursement for communication, consultation, coordination, interdisciplinary care, telemedicine, and also behavioral, developmental, and mental health services furnished by primary care providers.

E. Develop new financial incentive programs to promote collaborative arrangements between medical home providers and pediatric subspecialists.

F. Encourage public and private support for research and demonstration projects to evaluate outcomes of collaborative, interdisciplinary models of pediatric training and care delivery.

G. Establish public/private funding mechanisms, including grant programs, to support regional, State, and local collaborative planning to expand access to pediatric subspecialty care within the medical home.

H. Establish funding support for the use of technology and routine travel to rural and other underserved areas by pediatric subspecialists.

6. Improve the knowledge base regarding access to and quality of pediatric subspecialty care within the medical home model of care.

A. Work with family organizations to obtain data on pediatric subspecialty access difficulties.

B. Obtain workforce information on pediatric subspecialist clinical FTEs.
C. Prepare a uniform, consistent approach to needs assessment across all pediatric subspecialties.

D. Create new mechanisms for obtaining information on pediatric surgical and hospital-based specialties that are not boarded by the American Board of Pediatrics.

E. Examine health care outcomes among children receiving care in medical home practices with collaborative pediatric subspecialty care.

Children’s timely access to pediatric subspecialty care is an essential component of a comprehensive medical home. Unfortunately, all too many children are experiencing lengthy delays in obtaining needed subspecialty care. To accomplish critical improvements in pediatric care, these recommendations offer short- and long-term strategies that public and private agencies, health care providers, and payers can work on jointly.

Expert Work Group on Pediatric Subspecialty Capacity

Health Resources and Services Administration
Maternal and Child Health Bureau
Bonnie Strickland, PhD
5600 Fishers Lane
Rockville, MD 20857
Web site: www.hrsa.gov
E-mail: bonnie.strickland@hrsa.gov

Information about MCHB and its medical home programs are available at http://mchb.hrsa.gov/about/dscshn.htm.