BY JULIET B. UGARTE HOPKINS, MD
Just as the role of physician advisors has come to the forefront of the healthcare world over the last decade and a half, so too has the subset of pediatric physician advisors in recent years. While, previously, their scope and unique focus was side-stepped by the greater community due to a handful of key factors (not the least of which is state-by-state differences in Medicaid rules and regulations) their expanding ranks and the critical developments nationwide affecting hospital pediatric units and availability of pediatric services now make discussion about the importance and future of the role unavoidable.
Three years ago, the American College of Physician Advisors (ACPA) established their Pediatric Committee supported by chair Dr. Denise Goodman, medical director of case management and care coordination and pediatric intensivist at Ann & Robert H. Lurie Children’s Hospital of Chicago and professor of pediatrics for the Northwestern University Feinberg School of Medicine. Since then, their committee has grown to over 30 members with a larger and more involved contingent of pediatric physician advisors involved in the ACPA’s National Physician Advisor Conference (NPAC) as attendees and featured speakers year over year.
While the unique and impactful role of physician advisors first came to notoriety during the time of the Medicare Recovery Audit Contractor (RAC) audits and exploded from there, the path of recognition for pediatric physician advisors has been a bit more subtle. Pediatric services have never been considered financially impactful, especially within non-children’s hospital settings. Without routine, profitable, diagnostic and preventative procedures like colonoscopies and cardiac catheterizations as in the adult population and the harsh truth that Medicaid and managed Medicaid plans notoriously pay pennies on the dollar for reimbursement of services, the overarching understanding has been that pediatric cost of care will essentially break even for health systems. However, as we have seen in recent years as hospitals close their pediatric units, pediatric intensive care units, and cut back universally on their pediatric services on an inpatient and outpatient basis, getting paid less than expected for services provided is even worse than being paid what is expected for services provided. While pediatric medicine is advancing year over year for what decades ago were eventual death sentences by the time a patient reached adolescence, the capability of our nation’s hospitals and health systems to provide this astounding level of care is dwindling due to insufficient payment.
Anyone even remotely familiar with pediatric medicine knows there is no side-by-side comparison with the adult counterpart when it comes to many aspects of patient care. From clinical presentation and clinical trials to treatment modalities and FDA-approved pharmaceuticals, there often are stark differences or even a true lack of comparative data. One impactful example of this in the utilization management space is the content of common clinical guideline criteria used by case/utilization managers and payers for statusing patients. While they may have pediatric-specific criteria for a condition like hypertension, there often is nothing that even mentions major treatment pathways, which are usually only seen in pediatrics, such as initiation of a ketogenic diet.
Additionally, it is quite common for payer medical directors to misidentify the major factors of a case and try to fit complicated diagnoses into simplistic conditions. “I’ve been involved in peer-to-peers where a toddler had an inborn error of metabolism with metabolic crisis precipitated by an intercurrent illness,” recounted Goodman, “and the payer thinks it’s run-of-the-mill gastroenteritis or bronchiolitis. I’ve found myself explaining OTC [ornithine transcarbamylase]deficiency or some other genetic condition and talking them through the support needed.” She notes this is just one example of why hospitals which have pediatric departments – even if not a stand-alone children’s hospital – need physician advisors with pediatric expertise. The issue is not simply having internal staff who can appropriately identify patients meeting criteria for inpatient status, but who also have the ability to explain the reasoning to a payer medical director who lacks this expertise.
Readmission reduction and efforts toward optimizing hospital length of stay are just as important with pediatric patients as they are with adults. While provision of inpatient medicine is similar, that is not so when it comes to the outpatient setting. Organizations that provide intensive support in the home or specialized facility caregiving, which is sometimes needed to manage incredibly complicated diagnoses and conditions, are few and far between in the pediatric realm.
Network inadequacy for discharge planning is a common challenge. Case managers can obtain a list of 45 potential home health entities but then learn 40 of them do not accept patients under 18 years of age, three accept children but not those with central lines, and the final option has no staffing available for the foreseeable future. Unlike with Medicare, home nursing benefits often are for shifts of time, not interval visits for a focused indication like providing IV antibiotics twice a day. This means families have to muddle through learning the skill to provide it themselves, but if they are unhoused or the caregiver has cognitive or mental health issues, this can prevent discharge from the hospital entirely.
Similarly, even if intensive services are not needed, complicated social issues often can hold up a safe discharge for a patient who cannot even come close to caring for themselves. Physician advisors who are well-versed with these challenges can make a big impact in supporting their hospitals by anticipating the issues and proactively setting things into place to address them before multiple, medically unnecessary days pass with the patient remaining in the hospital setting.
Have you had difficulty appealing denials for acute respiratory failure or severity of a respiratory condition when your adult patients require just two liters per minute of supplemental oxygen to maintain normal oxygen saturation? Imagine your patient requiring just 0.1 liter per minute! Or, on the other end of the spectrum, picture making an argument for the severity of a toddler’s asthma exacerbation when his profound presenting signs and symptoms turned around in less than 48 hours with intensive treatment.
According to Dr. Alyssa Riley, incoming director, Physician Advisor of Clinical Documentation/Revenue Integrity at Nationwide Children’s Hospital Toledo and vice chair of the ACPA’s Pediatric Committee, top-hitting diagnoses in hospital pediatrics are not really different from the adult world including sepsis, acute respiratory failure and malnutrition. However, pediatric training and experience are required to ensure the subtleties of identification, stabilization and treatment of these conditions in children is completely illustrated in the documentation, captured by the coders and appreciated by the payers. “NICU [neonatal intensive care unit]and complex care populations require pediatric physician advisor collaboration with coders to help them understand the nuances of these cases,” Riley said. “I’d strongly advocate for a team of designated pediatric coders if a hospital has a pediatric population embedded within a larger adult healthcare system.” She also recommends including pediatric physician advisors in quality improvement initiatives related to complications and readmissions to emphasize the need for clear documentation and accurate coding.
One of the key roles physician advisors play is to maintain the financial health of hospitals so they can maintain the health of the communities they serve. It is high time health systems recognize the pediatric subset of these communities and the critical needs they require to grow up and develop into the educators, artists, change-makers and even medical professionals we will all rely on and be inspired by for generations to come.
Juliet B. Ugarte Hopkins, MD, is founder and CEO of Velvet Hammer Physician Advising LLC, president of the American College of Physician Advisors (ACPA), and a consulting physician advisor for Phoenix Medical Management, Inc. Clinically, Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade in addition to serving as medical director of pediatric hospital medicine and vice chair of pediatrics within a health system in northern Illinois. She is a national speaker including presentations at ACPA’s National Physician Advisor Conference and the Case Management Society of America’s annual conference and a frequent author of articles involving topics related to the physician advisor scope of work.
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