In this issue of Pediatrics, Bohnhoff et al1  reviewed 20 466 pediatric referrals from primary and urgent care offices in the University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh system to its affiliated subspecialists. Of these, 65% had an appointment scheduled within 90 days of referral initiation, and 51% had a completed visit within 90 days of referral initiation.1  Appointments with shorter lead times (elapsed time between scheduling the appointment and the date of the appointment) were more likely to be kept. African American race, public insurance, and lower zip code median income were associated with decreased likelihood of both scheduling and completing the appointment. In this study, the authors give a systemwide transparent view of the “administrative friction” experienced by clinicians, referral clerks, and families and provide insight into some of the rate-limiting steps in the referral process.

As the authors note, this study’s conditions represented a best-case scenario for referrals. Because the referring clinician and the subspecialty schedulers both documented referral information in the same electronic system, the chance of accidental referral loss between primary clinician and specialist is low. Because primary care pediatricians and specialists were part of the same health system, protocols for information sharing (eg, having primary care pediatrician records at the time of referral) and aligned insurance participation were likely to enhance the process. Behavioral health referrals, among the most challenging referrals to complete24  were not evaluated in this study.

Increased lead time does not necessarily reflect a scheduling failure. Consider the case of a working single parent who prefers Tuesday appointments, that being her usual day off work. It might be reasonable for her to decline earlier Wednesday and Friday appointments as she accepts a Tuesday appointment 2 to 3 weeks away. In fact, given that Medicaid transportation contractors often require a 2- to 3-day minimum notice before scheduling trips and impose other administrative restrictions that take time to navigate,5  an appointment made “too soon” may be at increased risk of breakage.

Because scheduled appointments had a 5-in-6 likelihood of being kept, the more important question appears to be why 1 in 3 referrals were not provided with a timely appointment. When a reason was given (47% of unscheduled appointments), failure to reach the family was more than 3 times as common as the family declining an appointment. Many patient-centered medical homes have improved their outreach outcomes by incorporating text messaging into their care coordination processes. Prepaid phone plans often have limited voice minutes and small-volume voice mailboxes in their plans, but many offer unlimited texting. A family who is unwilling to answer a call from an unfamiliar number might engage with a text message, whose purpose and provenance is inherently declared. If employees are prohibited from answering personal phone calls on work time, the benefit of having a live referral clerk contact the family during business hours is lessened. In contrast, a texting conversation can occur asynchronously; artificial intelligence support permits scheduling clerks to manage more referrals simultaneously.

Some pediatric specialties simply have too few physicians and/or physicians who are inequitably distributed geographically.6,7  In regions where, for example, 1 pediatric rheumatologist serves 850 000 children, all children (not just those with public insurance) might experience significant appointment lead times. To account for this variable, Bohnhoff et al1  stratified referrals into large– and small–appointment capacity specialties; the median time to scheduled appointment for large subspecialty capacity (median of 27 days) at University of Pittsburgh Medical Center Children's Hospital of Pittsburgh was not statistically different from that of small-capacity clinics (median of 24 days).

Finally, the authors of this study highlight the need for Medicaid plans to examine the federal mandate for equal access8 : children with public insurance waited longer (median of 29 days) than privately insured children (median of 23 days) for an appointment. The Centers for Medicare and Medicaid Services have instructed states to develop and submit an access monitoring review plan for Medicaid recipients.9  The American Academy of Pediatrics has provided extensive commentary on this important arena of child health equity.10  Pennsylvania’s current plan11  does not commit to measure specialty appointment lead time nor does it propose to consider, for example, pediatric cardiology as a separate specialty from internal medicine. Nevertheless, Pennsylvania expects that Medicaid members’ maximum wait times for routine specialist appointments be no more than 10 to 15 business days,12  similar to that of other states. It is unclear how a state plan can determine the success of its access metric if it is never formally measured. More work is needed to address the difference between the plan’s goal and current reality. Medicaid plans can partner with child health clinicians by reducing barriers (eg, reducing preauthorization paperwork burdens) and/or providing incentives (eg, per-member-per-month for care coordination, payment parity with Medicare or commercial payers) to further reduce specialist appointment lead time.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-0545.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Berman is an employee and shareholder of Connexin Software and Script Doctor LLC.