Every pediatrician and pediatric specialist can get involved in advocating for payment reform by starting conversations about the long-term benefits of child health and correcting a system that undervalues pediatrics, said AAP President Susan J. Kressly, M.D., FAAP.
“We have to really promote the value of pediatrics,” she said.
AAP News sat down with Dr. Kressly to discuss the issues, possible solutions and how AAP members can get involved. Following is an edited transcript of the conversation.
Q: What are the key payment issues that impact pediatricians and pediatric practices?
A: All pediatricians, including pediatric specialists and surgical specialists, are undervalued and underpaid. Global underpayment with under-resourcing parallels the country’s undervaluing of children. So, it should be no surprise that attention is not often paid to taking care of children, which means pediatricians are also undervalued.
Q: How do we change that?
A: It’s going to take multiple layers of advocacy. The first thing we have to do is understand what leverage we have.
If you are the top-performing quality practice in your region, you use that as leverage to say, “I need additional resources to continue to be high-quality.” You must know your own data.
Perhaps you are the only pediatrician in your county who takes Medicaid. Then your leverage is access.
Is your leverage that you have the lowest rate of hospitalizations in your area? Do your patients come to you because you have extended hours instead of going to the urgent care and the emergency room?
It’s understanding what makes you special from the payer side.
Q: Are practices on their own in this process?
A: Sometimes it’s working with others in your area. It could be your state pediatric council who understands how to motivate the major payers to make things happen.
If you’re dealing with a state that’s one commercial payer and Medicaid, it’s harder to negotiate, but it’s not impossible.
Size is a leverage. If you’re assimilated with like-minded people in your area, if you take care of more covered lives, you capture the payer’s attention.
I don’t want people to think that it’s impossible if you’re solo. If you’re a top performer in high quality and low cost, that translates to value to the payer, and you can affect change.
Q: What should pediatricians know about insurance?
A: About 50% of patients who you think have commercial insurance actually have employer-sponsored plans that are passed through a bigger payer. Talk to people in your community. “Did you know that your employees are missing work and worried about their child because, in part, your insurance is not paying for X, Y and Z in a way that their pediatrician can get paid to do it?”
The bulk of health care dollars are spent in the adult population, so kids are just not even considered. If you have a large payer in your community, you can create relationships and advocate for including children.
Q: Do you have personal experience doing this?
A: When I was the school district physician in Pennsylvania, I asked the people making decisions about insurance, “Do you understand the plan you picked — how it carves out some of the highest quality pediatricians in our neighborhood?”
It’s working with local businesses or your chamber of commerce. Just informing everyone you meet about how health insurance works and how children are undervalued and pediatrics is under-resourced and underpaid, and helping them understand that it’s not that your doctor wants to make more money to drive a Lamborghini. It’s that your doctor needs to be paid adequately to give the care that your kids deserve.
When you call your pediatrician and no one answers the phone, it’s because we’re not paid enough to hire people and pay them a living wage to answer the phone.
Q: How do you approach negotiations with an insurance company?
A: The real negotiation starts when you send a letter saying I’m terminating my contract, and I’ve notified my patients. They’re like, “No, no, no, don't talk to your patients.” Because those patients then go to their employer. Patients have more pull with the insurer.
I don’t care what the economy of your state is built on, it depends on healthy workers. That’s another reason we need to start talking to the chamber of commerce, locally, state level and nationally, because everybody cares about their workforce. If you’re the employer and you can’t find healthy workers to do the job, you’ve got a problem. We need to start talking about payment through the lens of: The future of our country depends on the health of children.
Q: How do payment issues impact the future of pediatrics?
A: Many trainees and people entering medical school have to be looking at a model where they make an informed business decision about debt.
If you don’t invest in primary care, the dollars spent go up exponentially. And if you don’t invest in pediatric specialty care, the spend also goes up. One way you incentivize pediatrics is to reduce the training debt.
The payment system rewards procedures, so pediatric specialists make less money than adult specialists. That has to be fixed.
Q: How can pediatricians get involved in payment advocacy?
A: Advocacy starts with curiosity. Why is it this way? Who thought it was a good idea and who made the decision? I want to talk to them, because I think they weren’t informed about some of the unintended consequences.
We must make sure every pediatrician understands that they’re a child health expert. Pick up your folding chair and invite yourself to every table, and it starts with your own family.
We need to talk to everyone about the importance of child health and its importance on the economy, its importance on military readiness, its importance on the health of our nation.
Q: What pain points are key right now?
A: I am concerned about the ongoing struggle of our members in Puerto Rico. Some of these committed pediatricians are willing to take on outside jobs to be able practice and care for their families. That's crazy. They need help to remain on the island and continue to provide care for the children of Puerto Rico.
The system we have hinges on assigned values from the Resource-Based Relative Value Scale Update Committee (RUC) and the American Medical Association. You can criticize the system and nothing happens. Or you can understand how it works, and while you’re trying to change the world, incrementally, gain traction.
In pediatrics, we always have at least two patients — a caregiver and a child, sometimes two caregivers who don’t agree. We must sort that out and do what’s right for the child in a complex world. What about a pediatric modifier that pays us 150% of the adult world? That is a simple solution that would change what we do, but we must paint the business case.
The other thing I would love people to understand is the Academy looks to its membership as the subject matter experts to propose solutions and get involved in doing the work. Then the AAP infrastructure can decide how to operationalize it. Members like you are the ideas and the action.
Q: What are some of the Academy’s advocacy success stories on this issue?
A: I think nirsevimab is a great example of how working together can effect change.
The work of the Committee on Coding and Nomenclature and the RUC to successfully advocate for and value the nirsevimab administration codes 90380 and 90381. While there continue to be some challenges, a multidisciplinary group of expert members met frequently to discuss implementation and payment barriers starting before the product was available. This led to more rapid adoption of appropriate coding and payment by the vast majority of payers. In addition, the Payer Advocacy Advisory Committee continues to work with AAP staff to push back against barriers such as prior authorization.
Q: What’s one piece of advice you would give pediatricians who are struggling with payment?
A: Ask for help. Too many pediatricians suffer in silence. There is no secret sauce except to join forces with other people who’ve done similar work and to learn from them. There are plenty of people at the chapter level and the national level who are more than happy to lift you up. Together we can make a difference for kids and for the profession of pediatrics.
