Mary Ellen Rimsza

Pediatrician workforce policy statement.

This policy statement reviews important trends and other factors that affect the pediatrician workforce and the provision of pediatric health care, including changes in the pediatric patient population, pediatrician workforce, and nature of pediatric practice. The effect of these changes on pediatricians and the demand for pediatric care are discussed. The American Academy of Pediatrics (AAP) concludes that there is currently a shortage of pediatric medical subspecialists in many fields, as well as a shortage of pediatric surgical specialists. In addition, the AAP believes that the current distribution of primary care pediatricians is inadequate to meet the needs of children living in rural and other underserved areas, and more primary care pediatricians will be needed in the future because of the increasing number of children who have significant chronic health problems, changes in physician work hours, and implementation of current health reform efforts that seek to improve access to comprehensive patient- and family-centered care for all children in a medical home. The AAP is committed to being an active participant in physician workforce policy development with both professional organizations and governmental bodies to ensure a pediatric perspective on health care workforce issues. The overall purpose of this statement is to summarize policy recommendations and serve as a resource for the AAP and other stakeholders as they address pediatrician workforce issues that ultimately influence the quality of pediatric health care provided to children in the United States.

The Use of Telemedicine to Address Access and Physician Workforce Shortages.

The use of telemedicine technologies by primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists (henceforth referred to as “pediatric physicians”) has the potential to transform the practice of pediatrics. The purpose of this policy statement is to describe the expected and potential impact that telemedicine will have on pediatric physicians’ efforts to improve access and physician workforce shortages. The policy statement also describes how the American Academy of Pediatrics can advocate for its members and their patients to best use telemedicine technologies to improve access to care, provide more patient- and family-centered care, increase efficiencies in practice, enhance the quality of care, and address projected shortages in the clinical workforce. As the use of telemedicine increases, it is likely to impact health care access, quality, and education and costs of care. Telemedicine technologies, applied to the medical home and its collaborating providers, have the potential to improve current models of care by increasing communication among clinicians, resulting in more efficient, higher quality, and less expensive care. Such a model can serve as a platform for providing more continuous care, linking primary and specialty care to support management of the needs of complex patients. In addition, telemedicine technologies can be used to efficiently provide pediatric physicians working in remote locations with ongoing medical education, increasing their ability to care for more complex patients in their community, reducing the burdens of travel on patients and families, and supporting the medical home. On the other hand, telemedicine technologies used for episodic care by nonmedical home providers have the potential to disrupt continuity of care and to create redundancy and imprudent use of health care resources. Fragmentation should be avoided, and telemedicine, like all primary and specialty services, should be coordinated through the medical home.

Impact of Medicaid disenrollment on health care use and cost.

OBJECTIVE. The objective of this study was to compare the health care use of children who are covered by public insurance and uninsured children who live in a large urban area and the potential impact of disenrollment on health care use and costs if these children become uninsured. METHODS. The 2004 health care transactions for 43313 uninsured children and 168722 children who were insured by Medicaid/State Childrens Health Insurance Program and living in the Phoenix metropolitan area were analyzed using a community-wide administrative health database (Arizona HealthQuery). Using a multivariate model of health care use by currently uninsured children, we examined the effect of 10% disenrollment of the children who were currently insured by Medicaid/State Childrens Health Insurance Program. RESULTS. A 10% disenrollment would increase the costs of health care in the community by

Enhancing the diversity of the pediatrician workforce.

3460398 annually, or

Enhancing Pediatric Workforce Diversity and Providing Culturally Effective Pediatric Care: Implications for Practice, Education, and Policy Making

2121 for each child disenrolled. This increase in costs is attributed to a shift of care from ambulatory settings to more expensive emergency departments and an increase in hospital days. We determined that 69% of the change in emergency department visits, 58% of the change in hospital stays, and 74% of the change in ambulatory visits would be attributable to the change in insurance status. CONCLUSIONS. Programmatic changes that result in disenrollment from public insurance programs will increase the number of emergency department visits and hospital days as well as the total community costs of health care. These increases in health care use can be expected to aggravate community problems of emergency department overcrowding and inpatient bed shortages. The majority of the changes in use are attributable to changes in insurance status, which results in a shift of care from less expensive ambulatory settings to emergency departments and increases in hospital days when children lose Medicaid/State Childrens Health Insurance Program coverage.

Physician Practice Revenues and Use of Information Technology in Patient Care

This policy statement describes the key issues related to diversity within the pediatrician and health care workforce to identify barriers to enhancing diversity and offer policy recommendations to overcome these barriers in the future. The statement addresses topics such as health disparities, affirmative action, recent policy developments and reports on workforce diversity, and research on patient and provider diversity. It also broadens the discussion of diversity beyond the traditional realms of race and ethnicity to include cultural attributes that may have an effect on the quality of health care. Although workforce diversity is related to the provision of culturally effective pediatric care, it is a discrete issue that merits separate discussion and policy formulation. At the heart of this policy-driven action are multiorganizational and multispecialty collaborations designed to address substantive educational, financial, organizational, and other barriers to improved workforce diversity.

The Effects of Cost-Shifting in the State Children’s Heath Insurance Program

This policy statement serves to combine and update 2 previously independent but overlapping statements from the American Academy of Pediatrics (AAP) on culturally effective health care (CEHC) and workforce diversity. The AAP has long recognized that with the ever-increasing diversity of the pediatric population in the United States, the health of all children depends on the ability of all pediatricians to practice culturally effective care. CEHC can be defined as the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions, leading to optimal health outcomes. The AAP believes that CEHC is a critical social value and that the knowledge and skills necessary for providing CEHC can be taught and acquired through focused curricula across the spectrum of lifelong learning. This statement also addresses workforce diversity, health disparities, and affirmative action. The discussion of diversity is broadened to include not only race, ethnicity, and language but also cultural attributes such as gender, religious beliefs, sexual orientation, and disability, which may affect the quality of health care. The AAP believes that efforts must be supported through health policy and advocacy initiatives to promote the delivery of CEHC and to overcome educational, organizational, and other barriers to improving workforce diversity.

Financing graduate medical education to meet the needs of children and the future pediatrician workforce

Objectives:Although information technology (IT) may improve efficiency and quality of patient care, the adoption of clinical IT by physicians has been limited. This study investigates the relationships between physician practice revenue and use of clinical IT. Research Design:We undertook a cross-sectional analysis of data on 6849 U.S. physicians in physician-owned practices who responded to the 2000–2001 Community Tracking Study Physician Survey. Physician practice revenues, measured as the percentage of total revenues, is defined along 2 dimensions: type (capitation, noncapitated managed care, or fee-for-service) and source (Medicare, Medicaid, or private/other). Analyses were adjusted for physician and practice characteristics and geographic location. Measures:The proportion of physicians using IT for 5 functions of patient care: treatment guidelines, formularies, patient notes or lists, electronic prescriptions, and data exchange with other physicians. Results:Practice revenues are associated with differences in physicians’ use of IT in patient care. Above-average Medicaid revenue was associated with 20% higher use of IT overall (incidence density ratio = 1.20, 95% confidence interval [CI] = 1.12–1.30). Above-average capitation revenue corresponds to higher use of IT overall (incidence density ratio = 1.10, 95% CI = 1.02–1.19) and greater odds of using IT for guidelines (odds ratio = 1.26, 95% CI = 1.05–1.53). Above-average noncapitated managed care revenue, however, has no apparent relationship with IT use. Conclusions:Differences in the type and source of physician revenues were associated with differences in the use of IT in patient care in 2000–2001. The relationships between practice revenues and IT use varied across clinical IT functions.

Scope of Practice Issues in the Delivery of Pediatric Health Care

OBJECTIVES Many states are increasing the State Childrens Health Insurance Program (SCHIP) cost-sharing requirements to induce reductions in enrollment. We examined the effect of increasing SCHIP premiums on both health care use and cost to the public. METHODS The net cost to the public of increased cost sharing for SCHIP-insured children in a border community was estimated with multivariate methods. The majority (88%) of children were of Mexican origin. RESULTS We estimated that a

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10 increase in monthly premiums would induce 10% of SCHIP children to disenroll, resulting in a 6% increase in public expenditures. CONCLUSIONS Families that disenroll from SCHIP and become uninsured typically turn to emergency departments for primary care, which increases total health care expenditures through the use of more expensive services.