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Equitable access to pediatric subspecialty care requires improvements in collaboration, financing, education, research: report

September 7, 2023

A new report from the National Academies of Sciences, Engineering, and Medicine is calling for bold strategies to improve access to pediatric subspecialty care and advance the health of children.

The report’s 13 recommendations cover financial and payment incentives, enhanced education and recruitment, support of physician scientists, and better collaboration between primary care pediatricians and pediatric subspecialists.

Many of the findings and conclusions align with AAP policy and advocacy efforts.

The consensus report The Future Pediatric Subspecialty Physician Workforce: Meeting the Needs of Infants, Children, and Adolescents released by an ad hoc committee of child health experts identifies four goals:

  1. Promote collaboration and the effective use of services between pediatric primary care clinicians and subspecialty physicians.
  2. Reduce financial and payment disincentives to subspecialty careers.
  3. Enhance education, training, recruitment and retention.
  4. Support the pediatric physician-scientist pathway.

Sponsored by the AAP and seven other medical organizations, the report focuses on the 15 subspecialties certified by the American Board of Pediatrics (ABP). It highlights the need for broad access to quality care for all children, use of innovative models and health care technologies, flexible training pathways, a robust research portfolio and appropriate payment.

The report describes the changing demographics and needs of the U.S. pediatric population and the workforce required to support it.

Strengths, weaknesses of report

AAP President Sandy L. Chung, M.D., FAAP, said she was pleased to see the report highlighted important advocacy points, including loan repayment, alternative training pathways and physician payment.

“Ultimately, payment and the inequities in payment compared to adult medicine have led us somewhat to the situation that we’re in,” she said, referencing conversations with pediatricians and pediatric medical and surgical subspecialists from around the country.

“The inability to fill some residency and fellowship slots has been quite challenging.”

Overall, the recommendations were embraced by representatives of the sponsoring health care organizations and other AAP leaders.

“The report is a highly important effort from the National Academies, supported by multistakeholder groups including the AAP. It will help us better address pediatric subspecialty workforce needs, now and into the future. ...” said Harold K. Simon, M.D., M.B.A., FAAP, chair of the AAP Committee on Pediatric Workforce.

Others said the action steps and conclusions could have gone further. They would like to have seen more attention placed on equity issues — the systemic barriers many families face in accessing and navigating health care and other supports and services.

Some noted there also could have been more emphasis on the importance of family-centered care, as well as the role of community partners beyond the health care setting.

“The report is a good start, but the suggestions could be made more actionable and need to happen as soon as possible to effect change,” one observer noted.

Addressing barriers to strong subspecialty workforce

About 10%-20% of U.S. children visit a pediatric subspecialist annually. However, various factors influence whether patients get connected to subspecialty care, such as geographic barriers, type of insurance, referral patterns and availability of subspecialists.

Major disincentives exist for those who consider these careers. There are multiple barriers, with added challenges for individuals from groups underrepresented in medicine, whose numbers have not changed much over the past several decades.

In addition, recruiting into pediatrics needs to happen early and often, with increased exposure during medical school. Without this, the chance of recruiting into the subspecialties compared to other disciplines and general pediatrics will remain low.

“Achieving a robust subspecialty workforce will require concerted efforts across federal and state governments, pediatric professional societies, major pediatric education and training organizations, medical schools and fellowship programs, and health systems, with input from patients and families,” the report states.

The report calls on Congress to increase funding for the Pediatric Subspecialty Loan Repayment Program, which recognizes the burden of debt as a major barrier to subspecialty workforce development.

The relative value unit (RVU) system undervalues pediatric subspecialty care, according to the report, which suggests the Centers for Medicare & Medicaid Services prioritize services for children in assigning RVUs. The report goes on to say that Medicaid, the payer for the majority of children, can be used as a way to invest in children's health services. Higher Medicaid payment aligns with AAP's advocacy efforts to improve Medicaid and create a more equitable health care system.

A National Academies spokesperson said that its Office of Congressional and Government Affairs plans to reach out to relevant congressional committees.

There also are concerns about the current and future availability of pediatric subspecialists in both clinical and research settings. But increasing the number of subspecialists alone is not the answer; a more comprehensive approach is needed, said Frederick P. Rivara, M.D., M.P.H., FAAP, chair of the committee that issued the report.

More than half of ABP-certified pediatric subspecialists work in medical school or university settings, although telehealth and outreach clinics help mitigate these geographic barriers.

Education and training present additional challenges. A growing proportion of children have long-term medical and mental and/or behavioral health conditions, yet “the model of education and training has not evolved substantially in response to the changing context of society and medical practice, including pediatric patients’ health needs and practice patterns,” the report states.

Nearly all ABP-certified fellowships require three years of training, with a minimum of 12 months of clinical training and 12 months of scholarly work such as research. Yet almost half of practicing subspecialists report no involvement in research activities.

Recommendations include the need to review and adjust educational and training curricula for pediatric residents and fellows, and explore fellowship training pathways, including a two-year option for those who aspire to a career with a primary focus on clinical care.

Those reforms could help alleviate another burden: debt.

Many pediatric subspecialists face higher debt due to longer training and lower salaries. Women, who already earn less, make up a growing proportion of the workforce, and fewer female subspecialists report working full time.

Financial considerations also impact decisions to pursue research, the report found.

“The payment challenges for subspecialists reflected in this report add to what we already know is a tenuous financial infrastructure for pediatrics,” Dr. Chung said, “and it’s our hope that some of the recommendations outlined here will help us improve the overall pediatric care financing system.”

Another recommendation calls on Congress to provide federal funds within five years to states to increase Medicaid payment rates for pediatric services to achieve or exceed parity with Medicare payment rates.

Raising Medicaid funding levels at least to the level of Medicare is central to the guidance in the recent AAP policy statement The Unique Value Proposition of Pediatric Health Care,

The committee suggested that the Agency for Healthcare Research and Quality should submit a biennial report to the secretary of the U.S. Department of Health and Human Services on the changing demands and needs for pediatric primary and subspecialty care, the status of access to that care and disparities in receipt of those services.


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