Thomas K. McInerny

Physician reimbursement levels and adherence to American academy of pediatrics well-visit and immunization recommendations

Background. There is concern that commercial health insurance reimbursement levels for immunizations and well-child visits may not be meeting the delivery and practice overhead costs within some areas of the country. There is also concern that insufficient physician reimbursement levels may negatively affect the quality of children’s health care. Objective. We examined the relationships between commercial health insurance reimbursement levels to physicians for pediatric services and rates of immunization and well visits for children and adolescents. Design. Quality of care was measured by examining state-level immunization and well-visit rates for 2002, which were obtained from the National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS). Reimbursement data were obtained from the American Academy of Pediatrics Medical Cost Model. Variations in the child and adolescent HEDIS measures were examined as a function of physician reimbursement levels for pediatric services across states. HEDIS data were available for a total of 32 states. Partial correlations controlled for pediatrician concentration, as collected from the US Bureau of the Census and the American Medical Association Physician Masterfile data. Results. Compliance with HEDIS immunization rates for all recommended vaccines was 60% for children and 24% for adolescents. By excluding the varicella vaccine, these rates increased to 70% for children and 44% for adolescents. Adherence rates for well visits were also higher for infants (60%) and children (59%) than for adolescents (34%). Physician reimbursement levels for pediatric services varied from

Legal and ethical considerations : Risks and benefits of postpartum depression screening at well-child visits

16.88 per member per month to

Normal pulmonary function measurements and airway reactivity in childhood after mild bronchiolitis

32.06 per member per month across states. Statistically significant positive correlations for reimbursement levels were found for 8 of the 16 HEDIS measures examined. Correlations with reimbursement levels were found for childhood immunizations (r = 0.42), infant well visits (r = 0.44), childhood well visits (r = 0.46), and adolescent well visits (r = 0.42). Reimbursement levels were especially strongly related to the rates of adolescent varicella vaccination (r = 0.53). When partial correlations were examined to control for pediatrician concentration, the correlations were reduced by 0.09 on average, suggesting that pediatrician supply may serve as an intermediary of the reimbursement relationship. Conclusions. Immunization and well-visit rates for infants, children, and adolescents were positively linked with physician reimbursement rates for those services. Although methodologic limitations suggest caution when interpreting these findings, more attention should be given to physician reimbursement levels as a possible predictor of immunization and well-visit rates as measures of quality of care and to the importance of reimbursement levels for pediatrician recruitment.

Policy statement - Principles of pediatric patient safety: Reducing harm due to medical care

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric providers responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.

Physician Perspectives on Incentives to Participate in Practice-based Research: A Greater Rochester Practice-Based Research Network (GR-PBRN) Study

Concern about the long-term sequelae of bronchiolitis has been raised through studies of children hospitalized for bronchiolitis, but the long-term sequelae of mild bronchiolitis have not been studied. We assessed the hypothesis that 25 children with mild bronchiolitis (index subjects) were at greater risk for abnormalities of pulmonary function or airway reactivity to cold air between the ages of 8 and 12 years than were randomly selected, matched controls. There were no consistent differences in pulmonary function or airway reactivity between index and control groups. Airway hyperreactivity was found in five control subjects and three index subjects, and all children with symptomatic asthma were identified by cold air challenge. Our data suggest that children with a history of mild bronchiolitis are not at increased risk between ages 8 and 12 years for airway hyperreactivity or for abnormalities in pulmonary function.

Weighing the risks of consumer-driven health plans for families.

Pediatricians are rendering care in an environment that is increasingly complex, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown in the 10 years since the Institute of Medicine published its report To Err Is Human, and patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification. Pediatricians in all venues must have a working knowledge of patient-safety language, advocate for best practices that attend to risks that are unique to children, identify and support a culture of safety, and lead efforts to eliminate avoidable harm in any setting in which medical care is rendered to children.

The American Academy of Pediatrics and Quality Improvement

Objectives: To understand factors associated with primary care physician research participation in a practice-based research network (PBRN) and to compare perspectives by specialty. Methods: We surveyed primary care internists, family physicians, and pediatricians in Monroe County, New York, regarding their past experience with research and incentives to participate in practice-based research. We performed descriptive and tabular analyses to assess perceptions and used χ2 and analysis of variance to compare perceptions across the 3 specialties. Results: The response rate was 33%. The most frequently endorsed aspects of collaboration were the opportunity to enact quality improvement (78%), contribution to clinical knowledge (75%), and intellectual stimulation (65%). Significant differences among the primary care specialties were found in 2 aspects: (1) internists were more likely to endorse additional source of income as “important,” and family medicine physicians were more likely to cite the opportunity to shape research questions, projects, and journal articles as “important.” Conclusion: Physicians across all 3 specialties cited the opportunity to enact quality improvement and contribution to clinical knowledge as important incentives to participating in practice-based research. This supports the importance of strengthening the interface between research and quality improvement in PBRN projects. Further study is needed to assess reasons for differences among specialties if PBRNs are to become successful in research involving adult patients.

Increasing Identification of Psychosocial Problems: 1979–1996

aConsultant, American Academy of Pediatrics, Elk Grove Village, Illinois; bMaternal and Child Health Policy Research Center, Washington, DC; cChair, American Academy of Pediatrics Private Sector Advocacy Advisory Committee, Elk Grove Village, Illinois; dDepartment of Pediatrics, University of Colorado School of Medicine, Denver, Colorado; eChair, American Academy of Pediatrics Committee on Child Health Financing, Elk Grove Village, Illinois; fDepartment of Pediatrics, University of Rochester Medical Center, Rochester, New York; gDepartment of Practice and Research, American Academy of Pediatrics, Elk Grove Village, Illinois

Improved Access and Quality of Care After Enrollment in the New York State Children's Health Insurance Program (SCHIP)

From the American Academy of Pediatrics, Elk Grove Village, Ill The views expressed in this report are those of the authors and do not necessarily represent those of the USDepartment of Health andHuman Services, the Agency for Healthcare Research and Quality or the American Board of Pediatrics Foundation. The authors declare that they have no conflict of interest. Publication of this article was supported by the Agency for HealthcareResearch andQuality and the American Board of Pediatrics Foundation. Address correspondence to ThomasK.McInerny,MD, FAAP, Department of Pediatrics, Children’s Hospital at Strong, 601ElmwoodAve, Box 777, Rochester, NY 14642 (e-mail: Thomas_McInerny@urmc.rochester.edu).