With Health Care Reform, First Do No Harm . . .

By guest blogger, Rhonique Harris, MD, MHA, FAAP, Executive Director, Public Sector Partnerships, Children's National Medical Center, Child Health Advocacy Institute

On Wednesday Jan. 27, 2010, I had the distinguished honor of representing N.A.C.H. at a Capitol Hill briefing about the important role of Medicaid in the nation’s health care delivery system. I was personally and professionally driven to provide congressional staffers the perspective of a children’s hospital primary care physician working on the frontlines for America’s most vulnerable and marginalized beneficiaries of health care —Medicaid recipients. My perspective and my presentation were informed by my position as a salaried physician with Children’s National Medical Center in Washington, DC, physicians who receive loan repayment as part of the National Health Service Corps, and on behalf of the children and families I serve. 

As a physician employed by a children’s hospital that serves a high volume of Medicaid beneficiaries (54 percent), I am acutely aware of Medicaid’s low reimbursement rates and the critical importance of Medicaid Disproportionate Share Hospital (DSH) payments. Medicaid DSH funding is particularly important to children’s hospitals because Medicaid has historically paid twenty to forty percent below what it costs to provide care at children’s hospitals. However, even with current DSH payments, children’s hospitals still receive less than what it costs to provide care. Without sufficient DSH funds, children's hospitals nationwide will face severe financial challenges that will threaten access to critically needed services for all children in the District and across the country.

As a pediatrician in the District of Columbia, I have been providing services to children and families living in areas that are considered Health Professional Shortage Area (HPSA) by the federal Health Resources and Services Administration. I was also a recipient of the National Health Service Loan Repayment program for the first two years of my professional career. A community or region is designated a HPSA if the ratio of population to physician is greater than 2000:1, 3000:1 and 10:000:1 for primary care physicians, dentists and mental health providers, respectively. In my comments, I highlighted that Children’s National Medical Center, a 283-bed, non-profit children’s hospital that employs 500 physicians, commissioned the RAND Corporation to conduct a community pediatric health needs assessment. The study provided objective data of what is already known by frontline workers:

1. There is a great dearth of pediatric health care providers in areas of greatest need.
2. Families incur extended wait times to access pediatric subspecialists.
3. Poor health care outcomes can be mapped to areas of health profession shortages.

I also enlightened the audience on the reality that coverage is not a significant issue with the children of the District of Columbia (97.1 percent of our children are covered by Medicaid and CHIPRA) and we cover up to 300 percent of the federal poverty level. Despite almost universal health coverage, children in the District of Columbia face significant difficulty accessing the care and services they need. 

In my statements I addressed the fact that currently, Medicaid enrolls 1 in 4 children and the low reimbursement rates paid by the program place tremendous financial strain on all providers. For all physician services, on average Medicaid pays 71 percent of what Medicare would pay for the same service. However, this varies from state to state and from service to service. Due to payment levels, which do not cover the cost of care, many physicians do not accept or limit the number of Medicaid patients they are willing to accept. As states are forced to cut Medicaid payments further to help balance their budget, children enrolled in Medicaid may face even greater access challenges. Until Medicaid covers the cost of care provided to its beneficiaries, it will continue to discourage physician participation and leave its recipients facing long wait times, significantly delayed medical care, and increase usage of the emergency room.

Largely, my message to the Congressional staffers was one of equity in payment reimbursement such that there is leveling of the palying field of access to providers for Medicaid recipients when compared to their counterparts who have private or commercial insurance.

I couldn’t end without discussing the true experience that my patients and I have with limited access to pediatric subspecialists. The workforce issue is critical because regardless of how many children are “covered”, lacking access to needed health care has the same outcome as not having insurance.- prolonged wait times to specialist for chronic conditions, utilization of the emergency department for non-urgent conditions and overall decrease in quality of life. 

Recently, NACHRI fielded a survey among children’s hospitals on pediatric sub specialist shortages and their affect on children’s access to care. More than 40 children’s hospitals completed this survey, which revealed that children’s access to timely care is impeded by nationwide specialist shortages in high-demand specialties. The most severe specialists’ shortage areas are neurology, developmental-behavioral, gastroenterology, general surgery, and pulmonolgy. Survey respondents reported wait times that exceed prevailing benchmark of two weeks: Longest wait time is developmental-behavioral at 13 weeks, followed by neurology at 10 weeks. Comprehensive policy improvements are needed to address the serious problem of children’s access to care. Legislators must evaluate how to improve Medicaid reimbursement levels to encourage providers that are currently practicing medicine to expand their willingness to accept children covered by Medicaid.

I was compelled to share with the staffers and legislators two patient vignettes that highlighted much of my concerns as a Medicaid provider:

K.T. is an eight year-old female treated for worsening peri anal and peri vulva rash (with itching and burning) in the emergency department (ED) at a hospital during the Christmas holiday. The patient received follow up care with primary care physician on Jan. 8, 2010. K.T. was referred to a dermatologist for further assessment of her condition. Due to her insurance, K.T. has limited options for specialty care. Her options included scheduling a dermatology appointment at one of the hospitals in the area or with the one community provider that participates with her insurance carrier. Each location had a three to four month wait period for an appointment. She was scheduled at our children’s hospital and will not be seen until May 10, 2010 (4 month delay). During this wait period, KT is at risk for a worsened health condition with another possible ED visit or repeated visit to her primary care provider. 

L.C. is a seven year-old male referred by his primary care physician on Dec. 7, 2009 to an Otolaryngologist (ear, nose & throat) for removal of foreign body in his ear. He also reported some hearing loss. His appointment was scheduled for 6 weeks after his original visit and complaint to his primary care physician. This child’s only alternative was to go to the ED.

Both scenarios show the impact that the lack of access to care will have to their quality of life and their ability to function. Their medical conditions will have an impact on their ability to learn and thus become productive citizens in society. At the end of the day, when we are thinking of health care reform, let’s think of our nations’ most valuable resource, our children. When I took the Hippocratic oath in medical school, I committed to “First do no harm.” If I were to sit by and not communicate to policy makers the realities faced by families and physicians, I would be doing harm. I ended with advice to the staffers and Members of Congress: When considering you the next steps in health reform — remember to first do no harm.