The Wall Street Journal
A growing shortage of pediatricians trained in specialties such as neurology, gastroenterology, and developmental and behavioral medicine is threatening timely access to care for children, according to pediatric medical groups.
As the House and Senate intensify the process of melding their two health bills, pediatric groups are lobbying to secure more funding for training and higher reimbursement for pediatric sub-specialties, in the hope of encouraging more doctors-in-training to enter the field. Specialization typically requires up to three years of training beyond a general pediatrics residency and can pay salaries less than half the rate of adult specialty medicine. At present, 17 states lack at least one physician in one of 13 sub-specialties.
Wednesday, in a briefing for members of a congressional caucus on children's health, the National Association of Children's Hospitals and Related Institutions, known as Nachri, will present results of a December survey. In it, members said that shortages of doctors across a multitude of pediatric sub-specialties are forcing 90% of hospitals to delay appointments, lose patients or refer them elsewhere.
Of particular concern, given the rise in autism-related disorders, is a shortage of development-behavioral experts; half of hospitals in the survey reported that it takes more than three months to see a developmental pediatrics specialist, one of the longest wait times.
Jim Kaufman, Nachri's vice president for public policy, says its 200 members on average devote half their caseloads to children from low-income families who are covered by the federal Medicaid program, which reimburses pediatric sub-specialists on average at 30% below what the Medicare program reimburses adult specialists. The group is counting on a provision in the House bill that would require Medicaid to pay Medicare rates for office visits to most providers, which could boost subspecialist pay.
Thanks to advances in medicine such as better care of premature infants, many children are alive who may have died in the past. "We've done a good job of caring for kids with complex medical problems, but we've created a generation of kids who need ongoing and continuing care for serious issues," says Arthur Pickoff, chairman of pediatrics at Children's Medical Center of Dayton, Ohio. His hospital has struggled to fill jobs in gastroenterology, neurology and pediatric surgery and is looking at ways to raise more money for training, such as reducing spending on urgently needed capital projects.
Nachri says 44 hospitals employing 3,000 sub-specialists responded to the survey, representing about 40% the children's hospitals that train half of all pediatric sub-specialists. The hospitals also reported that jobs for the top specialties are going unfilled for a year or longer; nearly half reported vacancies in pediatric-rehabilitation medicine, hematology and oncology, and cardiology.
For families, that often means waiting for months to see a specialist and incurring heavy travel costs, often to another state. Three-year old Kenneth Jones, for example, was born in Alaska with a rare gastrointestinal disorder that made him unable to absorb protein. He had to travel three hours to see one pediatric GI specialist in the state—a doctor who left a year later. The family moved to Oregon for work-related reasons and found a clinic that could provide complete care for the disorder—in Ohio, at a Cincinnati Children's Hospital clinic where they had to wait seven months for Kenneth's first appointment.
"There are so few pediatric GIs out there and so many children that need to be seen that you just have to wait in line," says Kenneth's mother, Lauren Jones. "That's the hardest thing to endure for a parent with a sick child who needs help right away."
For example, nearly 300,000 children suffer rheumatic diseases such as rheumatoid arthritis, characterized by inflammation of joints, muscles or tendons. Pediatric rheumatologists have been trained to treat the complex and sometimes life-threatening diseases, but fewer than 200 are in practice in the U.S.; 13 states lack a pediatric rheumatologist, and children on average travel 57 miles to the nearest one, according to the federal Department of Health and Human Services. Pay for the specialists is even lower than other pediatric sub-specialists; in 2007, salaries averaged $115,022, compared with $144,000 for pediatric cardiology, neonatal medicine and pediatric critical care.
The Senate bill contains a measure that would fund a loan-forgiveness program for pediatric sub-specialists, easing the financial burden of medical-school costs. "While most of us are driven into this profession because we love kids, the vast majority leave training with huge debt and the prospect of not making very much money at the end," says John McBride, a pediatric pulmonologist at Children's Hospital Medical Center of Akron, Ohio, who cares for children with a number of diseases including cystic fibrosis.
The federal Medicare program funds training programs for adult medicine. Congress five years ago authorized funding for pediatric specialty training, but the funds must be re-authorized every year. Nachri is asking for $330 million for funding for fiscal 2011, up from the $317.5 million appropriated for fiscal 2010.
The American Board of Pediatrics currently certifies or jointly certifies 20 pediatric subspecialties, not including neurology and surgical subspecialties. In 2008, there were close to 19,000 certified pediatric sub-specialists, compared to about 15,000 five years earlier. But while there has been an increase in the number of pediatric residents choosing to enter sub-specialty programs, fewer are finishing the training, leading to an overall decline in the number of doctors who chose pediatric specialties. And while the pipeline of trainees is increasing in some specialty areas, large gaps still exist between demand and supply in many pediatric specialty areas, according to James Stockman, president and chief executive of the American Board of Pediatrics.
"We are really in a crisis mode" says Beth Pletcher, a professor at New Jersey Medical School who chairs a committee on work-force issues for the American Academy of Pediatrics. When Dr. Pletcher recently tried to refer a patient to a pediatric endocrinologist, she learned that there was a six-month waiting list—and the doctor wasn't taking any new patients.
One problem is that specialists tend to cluster close to large academic medical centers, in areas where there is a population large enough to sustain a practice. But in a survey of its members, to be published later this year, the American Academy of Pediatrics found that while the greatest shortages are in rural areas, the majority of general pediatricians in all geographic areas considered wait times to be excessive when referring patients to sub-specialists.
To cope with the problem, many hospitals are turning to strategies such as telemedicine—remote consultations using two-way video systems—and mobile vans that may drive hundreds of miles to set up clinics in under-served areas. Hospitals are also more often turning to adult specialists to treat children, though not all are willing to do so. Surgeons, for example, may refuse to operate on children, because they aren't trained to deal with the differences in their physiology.
"Children are not just small adults, they have unique characteristics and different responses to medications and side effects," says Dr. Pletcher. "Given the choice, you want your child to see a pediatric sub-specialist."
As the House and Senate intensify the process of melding their two health bills, pediatric groups are lobbying to secure more funding for training and higher reimbursement for pediatric sub-specialties, in the hope of encouraging more doctors-in-training to enter the field. Specialization typically requires up to three years of training beyond a general pediatrics residency and can pay salaries less than half the rate of adult specialty medicine. At present, 17 states lack at least one physician in one of 13 sub-specialties.
Wednesday, in a briefing for members of a congressional caucus on children's health, the National Association of Children's Hospitals and Related Institutions, known as Nachri, will present results of a December survey. In it, members said that shortages of doctors across a multitude of pediatric sub-specialties are forcing 90% of hospitals to delay appointments, lose patients or refer them elsewhere.
Of particular concern, given the rise in autism-related disorders, is a shortage of development-behavioral experts; half of hospitals in the survey reported that it takes more than three months to see a developmental pediatrics specialist, one of the longest wait times.
Jim Kaufman, Nachri's vice president for public policy, says its 200 members on average devote half their caseloads to children from low-income families who are covered by the federal Medicaid program, which reimburses pediatric sub-specialists on average at 30% below what the Medicare program reimburses adult specialists. The group is counting on a provision in the House bill that would require Medicaid to pay Medicare rates for office visits to most providers, which could boost subspecialist pay.
Thanks to advances in medicine such as better care of premature infants, many children are alive who may have died in the past. "We've done a good job of caring for kids with complex medical problems, but we've created a generation of kids who need ongoing and continuing care for serious issues," says Arthur Pickoff, chairman of pediatrics at Children's Medical Center of Dayton, Ohio. His hospital has struggled to fill jobs in gastroenterology, neurology and pediatric surgery and is looking at ways to raise more money for training, such as reducing spending on urgently needed capital projects.
Nachri says 44 hospitals employing 3,000 sub-specialists responded to the survey, representing about 40% the children's hospitals that train half of all pediatric sub-specialists. The hospitals also reported that jobs for the top specialties are going unfilled for a year or longer; nearly half reported vacancies in pediatric-rehabilitation medicine, hematology and oncology, and cardiology.
For families, that often means waiting for months to see a specialist and incurring heavy travel costs, often to another state. Three-year old Kenneth Jones, for example, was born in Alaska with a rare gastrointestinal disorder that made him unable to absorb protein. He had to travel three hours to see one pediatric GI specialist in the state—a doctor who left a year later. The family moved to Oregon for work-related reasons and found a clinic that could provide complete care for the disorder—in Ohio, at a Cincinnati Children's Hospital clinic where they had to wait seven months for Kenneth's first appointment.
"There are so few pediatric GIs out there and so many children that need to be seen that you just have to wait in line," says Kenneth's mother, Lauren Jones. "That's the hardest thing to endure for a parent with a sick child who needs help right away."
For example, nearly 300,000 children suffer rheumatic diseases such as rheumatoid arthritis, characterized by inflammation of joints, muscles or tendons. Pediatric rheumatologists have been trained to treat the complex and sometimes life-threatening diseases, but fewer than 200 are in practice in the U.S.; 13 states lack a pediatric rheumatologist, and children on average travel 57 miles to the nearest one, according to the federal Department of Health and Human Services. Pay for the specialists is even lower than other pediatric sub-specialists; in 2007, salaries averaged $115,022, compared with $144,000 for pediatric cardiology, neonatal medicine and pediatric critical care.
The Senate bill contains a measure that would fund a loan-forgiveness program for pediatric sub-specialists, easing the financial burden of medical-school costs. "While most of us are driven into this profession because we love kids, the vast majority leave training with huge debt and the prospect of not making very much money at the end," says John McBride, a pediatric pulmonologist at Children's Hospital Medical Center of Akron, Ohio, who cares for children with a number of diseases including cystic fibrosis.
The federal Medicare program funds training programs for adult medicine. Congress five years ago authorized funding for pediatric specialty training, but the funds must be re-authorized every year. Nachri is asking for $330 million for funding for fiscal 2011, up from the $317.5 million appropriated for fiscal 2010.
The American Board of Pediatrics currently certifies or jointly certifies 20 pediatric subspecialties, not including neurology and surgical subspecialties. In 2008, there were close to 19,000 certified pediatric sub-specialists, compared to about 15,000 five years earlier. But while there has been an increase in the number of pediatric residents choosing to enter sub-specialty programs, fewer are finishing the training, leading to an overall decline in the number of doctors who chose pediatric specialties. And while the pipeline of trainees is increasing in some specialty areas, large gaps still exist between demand and supply in many pediatric specialty areas, according to James Stockman, president and chief executive of the American Board of Pediatrics.
"We are really in a crisis mode" says Beth Pletcher, a professor at New Jersey Medical School who chairs a committee on work-force issues for the American Academy of Pediatrics. When Dr. Pletcher recently tried to refer a patient to a pediatric endocrinologist, she learned that there was a six-month waiting list—and the doctor wasn't taking any new patients.
One problem is that specialists tend to cluster close to large academic medical centers, in areas where there is a population large enough to sustain a practice. But in a survey of its members, to be published later this year, the American Academy of Pediatrics found that while the greatest shortages are in rural areas, the majority of general pediatricians in all geographic areas considered wait times to be excessive when referring patients to sub-specialists.
To cope with the problem, many hospitals are turning to strategies such as telemedicine—remote consultations using two-way video systems—and mobile vans that may drive hundreds of miles to set up clinics in under-served areas. Hospitals are also more often turning to adult specialists to treat children, though not all are willing to do so. Surgeons, for example, may refuse to operate on children, because they aren't trained to deal with the differences in their physiology.
"Children are not just small adults, they have unique characteristics and different responses to medications and side effects," says Dr. Pletcher. "Given the choice, you want your child to see a pediatric sub-specialist."
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