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Policy recommends financing reforms to improve adolescent health care :

November 19, 2018

Many factors discourage access to health care for adolescents and young adults just at the time they are entering critical developmental periods.

Despite improvements made possible by the Affordable Care Act (ACA) and federal laws on mental health parity, adolescents’ care is jeopardized by lack of insurance, limitations in coverage, variability across plans, lack of confidentiality in billing and insurance claims, and high cost-sharing expenses.

A new AAP policy statement offers financing strategies to improve the health of this age group while ensuring that clinicians receive adequate payment for services.

Targeted Reforms in Health Care Financing to Improve the Care of Adolescents and Young Adults, from the Committees on Adolescence and Child Health Financing, is available at and will be published in the December issue of Pediatrics.

Improvements needed

The recommendations are mostly aimed at federal and state agencies and insurers. They call for efforts to reduce the number of uninsured, update standards for essential health benefits, include preventive services without cost-sharing, protect patient confidentiality, allow cost-effective access to behavioral health services and monitor the impact of the ACA on adolescent/young adult care.

“We focus on the fact that preventive services really should be available in all plans without cost-sharing,” said Mark L. Hudak, M.D., FAAP, a lead author of the policy. “It is especially important that adolescents and young adults have regular preventive care — and this should be the goal of all payers, not only federal but also commercial and TriCare.”

The Centers for Medicare & Medicaid Services could have more clearly defined essential health benefits, he added, rather than leaving it up to the states.

To address physician payment of adolescent services, including care related to behavioral concerns and sexual and reproductive health, the policy suggests providers maximize billing codes and use add-ons to the extent that they are allowed (see resources).

“There are so many challenges around billing and capturing the level of care that’s needed to provide quality services to adolescents,” said Arik V. Marcell, M.D., M.P.H., FAAP, the lead author of the policy. He mentioned research that showed providers spend about 36 seconds or less asking about sexual activity in a typical appointment.

“And that’s just one out of many areas that are critical to addressing adolescents’ health: understanding the context they live in, safety in their neighborhood and schools, behaviors they may be engaging in related to drugs … or issues related to mood or behavior,” Dr. Marcell said.

Another problem discouraging adolescents from going to the physician is concern over lack of confidentiality. This has been complicated by lack of confidentiality protections in explanation of benefits and the exposure of information in patient portals that link with electronic medical records. When advocating for improvements in confidentiality, providers can hold up states with better practices, such as California, Dr. Marcell said.

At a minimum, he hopes the statement helps providers talk to their policymakers to push the continued support of the ACA and the equity requirements. More education also is needed to better articulate the importance of health promotion and disease prevention to families and adolescent patients, so they understand what the role of the pediatrician can be, said Dr. Marcell.

“Addressing problems that begin in adolescence,” he added, “is such an important opportunity from a life course perspective.”

The care of adolescents and especially of young adults hasn’t gotten as much attention as it should, Dr. Hudak said.

“If you don’t have a job that gives you good insurance, you’re not in a family that’s insured or if you’re not in a Medicaid expansion state, you are likely in a hard spot,” he said. “This is an important public policy issue and, hopefully, the statement will raise the consciousness of people who can influence decisions that will help our adolescents and young adults.”

Key recommendations

  • Federal and state agencies should work to improve the number of insured adolescents and young adults and increase efforts to see that coverage is comprehensive and affordable. Preventive services need to be provided without member cost-sharing.
  • Insurers’ claim systems should recognize/pay for all preventive medicine Current Procedural Terminology (CPT) codes related to health and behavior assessment, counseling, risk screening and/or appropriate interventions as recommended in Bright Futures. Services should not be bundled under a single health maintenance CPT code.
  • Government and private insurance payers should increase the relative value unit allocation and level of payment for those delivering care and preventive services to a level commensurate with the time/effort expended, including for health maintenance services, screening and counseling.
  • All insurance plans have an ethical and regulatory imperative to implement billing and claims strategies that ensure patient confidentiality for appropriate services.
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