Pediatric councils bringing payers to the table to discuss local health care financing

The Academy is “dedicated to the health of all children” and that commitment pivots on the fiscal viability of the pediatricians who provide care for them.

Dr. Oken

The AAP Board of Directors has acknowledged the precarious financial situation of many pediatricians who have been forced to provide care and services for inadequate payment. “No margin, no mission” is a strategic goal voiced by the AAP Section on Administration and Practice Management.

Addressing these issues involves national, chapter and individual member dialogue with payers.

While the Academy cannot negotiate fees or payment rates due to antitrust concerns, it is addressing payer issues through meetings with national carriers and regional plans (see related article on page 14). These issues also are being addressed by chapter pediatric councils. The purpose of a pediatric council is to develop relationships and trust with local payers to resolve issues that impede the delivery of high-quality care to children.

Pediatric councils often can find success where an individual pediatrician or group practice cannot. An individual or practice group's attempt to approach a managed care organization (MCO) often will be ignored as a complaint from an unhappy provider or a minority perspective. Often, no response is elicited from a complaint left on the voice-mail of a medical director or the provider services representative.

The pediatric council, comprised of interested and informed physicians, establishes face-to-face meetings with key MCO decision-makers to discuss and solve issues on a continual basis. Issues include eligibility determination, credentialing, referrals, vaccine costs, bundling of services, and denied payment for preventive care and mental health services. Currently, 24 AAP chapters are tapping into the power of the pediatric council concept and bringing payers to the table.

While pediatric councils cannot discuss fees or set payment rates, they can educate payers on the impact of costs, carrier coverage and administration policies on pediatric care, including practice operations, access and quality.

Pediatric councils have seen both progress toward and solutions to issues. The most common, and most basic, role has been identifying key contacts and establishing an ongoing rapport with carriers. Once these contacts have been established, addressing specific issues commences. Some examples include:

• HealthNet rescinded its policy requiring prior approval for the preservative-free influenza vaccine as a result of contacts made by the AAP Connecticut Chapter and the Academy.

• The pediatric council in Penn sylvania has developed good rapport with medical directors of most private insurers and Medicaid. This has led to recognition by most insurers of mental health codes. In addition, the council has provided key recommendations for a pay-for-performance program that Medicaid is developing.

• Payers in Massachusetts have agreed to cover annual physicals on an 11-month timeframe as opposed to the calendar year.

• In New Jersey, coverage and payment was secured for lead screenings in the pediatrician's office.

• Blue Cross and Blue Shield of Rhode Island enhanced payment for after-hours care in the physician office (CPT code 99050) after a pediatric council presentation on emergency department utilization and the value and cost savings by avoiding ED visits.

• In Utah, benefits coverage was enhanced for asthma medications by working with carriers to categorize certain asthma controllers to Tier 1 level formularies.

These successes do not occur overnight. It takes time and the continued interest of a group of physicians who develop expertise about local health care financing and communicate with their peers about the problems in their community.

Dr. Oken is a member of the AAP Private Payer Advocacy Advisory Committee.