California Chapter 1
News Update August 1998

The Challenge to Increase Medicaid Reimbursement and Comparison of States’ Rates

By Edward B. Feehan

(Editor’s note: Dr. Feehan is a Merced pediatrician who has taken this issue on his own shoulders on top of his active pediatric practice. He believes that there is a large inequity of reimbursement. He seeks increased recognition by legislators to correct the problem. He has testified before Congress and found that they were disbelieving of some of the data presented. His campaign has generated well over 100 letters to communicate the issue. This article and additional tables are available at www.aapca1.org.)

Merced County in California has one of the highest unemployment rates in the nation and many of its children on Medicaid.

California is the richest state in the nation with a trillion dollars gross product but is paying the lowest rates for Medicaid. The reimbursement for a brief sick visit is $16.56 – using a standard brief visit of 99213. For most physicians California has not updated the rate of payment under Medicaid since 1985. A legislative chief of staff once told me that the federal government sets the rate for Medicaid. This was not true then and is not true now. Each state sets its own Medicaid rate. I am concerned that some legislators are still misinformed or are not willing to acknowledge the truth. States share the cost of Medicaid with the federal government. The present minimum share for the federal government is 50%. The formula is dependent on the average income in the state. Unfortunately the income of illegals is not allowed when determining the average income. In poor states the federal government picks up a higher percentage of the cost of care.

Each state enters into a written agreement concerning Medicaid and those documents are available from Health Care Financing Administration (HCFA). One of the specifications in these plans is that the rate for Medicaid shall be set after holding hearings to gather data and shall be set at a level resulting in Medicaid patients not having any greater difficulty finding a doctor than the general populace. Instead of raising general physician rates, California and other states have used subsidized clinics (rural health clinics and Federally Qualified Health Centers) to get around setting Medicaid rates high enough to keep pediatricians involved.

There is an 823% difference in payment for an encounter in the subsidized rural health clinic and a private office for the Medicaid patient. The rural health clinic can receive as much as $136.43 for an encounter verses $16.56 allowed for a pediatrician’s standard brief visit (99213). I testified in Congress in 1997 about this and the over 800% difference in payment levels. A member labeled my ratio absurd but it is accurate.

Recently I have gathered data from nearly every state by writing to each governor. Only New Jersey pays a lower rate for a 99213 than California, and only one state seems to have gone longer than California since their last update for Medicaid rates. Unfortunately, the federal government does not collect data about how much each state pays under Medicaid. It should but it doesn’t follow how often the rates are updated. I believe that there should be a mandated review and updating of Medicaid rates.

I have presented this data to Congress, some in person and some by letter (my letter count now exceeding 140). At the time I first wrote to each Governor, Alaska already had the highest rate of payment in the country at $53.52 per 99213 and they are presently updating to $62.92 by reason of RBRVS changes. In other words Alaska without any managed care is paying 379% higher than California at present for a 99213.

The richest state in the nation is paying the second lowest rate in the country. One reason is that 92% of our counties are labeled as having a shortage of physicians. Ironically Secretary of Health Shalala is telling the other cabinet secretaries that the US has one hundred thousand excess physicians.

This paper is written to alert my fellow pediatricians and other physicians about the process of Medicaid rate setting. With this information more pediatricians can educate their legislators who will understand the need to upgrade the rates. This will allow more pediatricians to serve poor children and improve their health.

(Editor’s note: You can find your legislator’s address through our website or contact Beverly Busher at our Chapter office.)

President’s Column

By Tom Long
President’s Mid Term Report

The end of the school year is a milestone that strikes me every June – recollections of my own graduation, my own children’s academic progress, and the prospects of summer. Well, this year I can add to that list – the end
of the California Chapter 1 fiscal year. You are all to be congratulated. We have done great things.

Once again the annual report is done. I think we should be recognized as an outstanding large chapter. We have to await our review. Highlights of my report include the outstanding work of our educational committee. I thought that every aspect of the Memorial weekend meeting was splendid. Our faculty, the program, the business meeting, and the social aspects were memorable.

We made some gains in Sacramento. Healthy Families is coming alive and the Medi-Cal benefits have been expanded. It still looks as though there will be recognition of the pediatricians when the new budget is finally approved. I think we will have a foundation for further discussions.

One of our members Sam Leavitt was the recipient of the Martin Gershman award and Cathy McDonald was recognized by the Academy for her contribution to counter the tobacco problem in children and teens. We had a planning retreat. We have some outstanding school related committee work on going. We sent some of our chapter members to AAP sponsored training programs such as the Firearms Injury Training Prevention program and the Legislative Training Conference. Our web page, thanks to Mark Simonian, is exemplary and keeps us all in touch. Our Chapter News Update newsletter also adds another dimension to our Chapter’s personality.

As we settle into the lazy days of summer the planning for next year is in the works. Two new standing committees, the Committee on Pediatric Emergency Medicine chaired by Jim Silva and Mary Rutherford and the Rural Pediatric Committee chaired by Arnold Gold, have been established. I am looking for a co-chair for the latter committee. Guess who’s coming to dinner, the Getting to Know You Dinner, on September 16, 1998? Our guest will be Nancy Snyderman whose candid medical commentary makes her a strong advocate for patients in need. The Chapter will again sponsor two Life After Residency Programs. I am sure by now you have all seen the program for the AAP annual meeting to be held right here in San Francisco October 17 - 21, 1998. I hope you will all plan to be there for at least a day. Immediately following the AAP meeting we will convene a CATCH Grant training meeting. We have unmet pediatric needs in our Chapter that need a little funding to get going. CATCH training can help us help others.

Want to know more? Your member-at-large can share the annual report with you. We had more pediatricians involved in Chapter activities this past year than at any time in recent memory. There is still a need for a little help from each and every member. What would you like to do?

I got a jump on summer as soon as the school bell rang spending an all too brief stay in Hawaii. A little rest recharges old batteries. I got a chance to reflect on our many accomplishments. Many people offer many resources and many ideas to make our chapter the success that it is. As much as we do, there is still work to be done. We now face another year of opportunity.

October will unveil our programs targeting alcohol abuse amongst teens, another addiction that often begins in the pediatric age group.  This is an important state election year as we prepare for gubernatorial elections. Remember the slogan, “Who’s for kids and who’s just kidding?” Challenge the candidates. What will we do about gun control and violence prevention?

On September 2, 1998, we are planning our 3rd annual Legislative Day in Sacramento. Our Board of Directors meeting will follow it. Why don’t you send your Member-at-large to that meeting with your agenda for 1998-1999? Let the resources of the Academy of Pediatrics help you to make your community a better place for kids.

District Chair Report

By Lucy S. Crain

One of the most significant contributions made by California, District IX of the AAP is that of the State Government Affairs Committee. Chaired by Robert Black of Monterey and more recently co-chaired by
Quynh Kieu of Fountain Valley, the Committee delivers a remarkable amount of service to the membership of our four California chapters. The Committee members, along with our members who act as legislative key contacts, review and often provide testimony either in hearings in Sacramento or in their legislators’ local offices. In concert with other child advocacy groups, the CMA, and the tireless efforts of our District Executive Director, Kris Calvin, the committee reviews approximately 1000 legislative bills related to child health or pediatric practice issues each session. The Committee recommends a District position (i.e. support, oppose, watch, etc.) on all relevant bills, and written comment is provided, often at length, by either Ms. Calvin, Dr. Black or Dr. Kieu, our lobbyist, or a designee. The District State Government Affairs (SGA) Committee is comprised of District and Chapter officers and Chapter representatives appointed by their Chapter Presidents.

As of July 15,1998, the District is without a contract lobbyist, as Ms. Erin Aarberg Givans recently wed and has chosen to resign her position with the California AAP. She is a remarkable child advocate, and we wish her well. However, we will continue to be well-served in Sacramento, as Ms. Calvin, who has had seven years of experience working with our State legislators, will assume the interim role of coordinating District lobbying efforts. This change also presents us with an opportunity to re-think our priorities as to the activities of our SGA Committee. We can readily list our SGA priorities as constituting three rather broad categories:

1. Access to child health care issues, including health insurance, immunizations and access to quality pediatric medical care (Title 21, Healthy Families, CHDP, CCS and services for children with special health care needs, etc. are included here.)

2. Medical and health care practice issues foremost of which is the campaign to obtain fair and adequate Medi-Cal reimbursement rates for pediatric services, but also including: legislation addressing scope of practice; inclusion of pediatric subspecialists in health plans including children; defining primary care physicians as including primary care pediatricians; opposing the scope of practice expansion to permit prescribing privileges to inadequately trained and unqualified categories of health practitioners, etc.

3. Child health advocacy issues including safety considerations such as swimming pool safety, school bus seat belts, air bags, bike helmets, violence prevention, etc.

Since the advent of legislative term limits, the educational and advocacy functions of the SGA and all District officers and members involved with legislative issues has increased enormously and promises to continue to do so. Our District leadership is actively networking with a number of child advocacy groups, who are developing a Children’s Platform addressing the priorities listed above, including collaborating on violence prevention, working toward universal insurance for children, and other pro-active activities. Similarly, we have strengthened our communication and collaboration with CMA lobbying efforts in the Medi-Cal reimbursement campaign.

Our legislative activities demonstrate a balance of advocacy for our profession and for children. But the number of relevant issues are at times overwhelming, and require the attention of all our members to inform their Chapter and District officers of what you consider most relevant. In other words, I want your wish lists. Please fax or e-mail to me or the District office the issues you would like the District SGA to focus on (Dr. Crain: lcrain@itsa.ucsf.edu, fax (415) 502-4191, or Ms. Calvin: kriscal@aol.com, fax (510) 559-8464). Give us no more than five issues which you consider most crucial to pediatricians and children in California and help us to better direct our prioritization as reflective of the concerns of our membership. Please do so as soon as possible, and we will include your feedback in the District Board discussions at our August 30 Board meeting.

I look forward to hearing from you. With your help we can be sure that
pediatricians and the children we care for are heard in Sacramento.

Adoption Committee

By Burt Sokoloff

Current Changes in Adoption Practices

In recent years there have been notable changes in adoption legislation trends in California. It remains essential for the pediatrician to be current in his knowledge in this field as he counsels adoptive families as well as those seeking to adopt. For selection of available adoptees in 1998 as always, there is an over-abundance of children in our foster care system available for adoption. New legislation has made it possible for these children to be adopted much earlier in life. The law no longer requires an extensive search for the birth parents of an abandoned baby. In many cases a lengthy try at rehabilitation of “unsuitable” birth-parents prior to relinquishment of their child is no longer required. As a result, younger infants are now available for adoption. Many babies have become available from the bible belt area of the U.S. Vista del Mar Child Care Agency recently stated that the “wait” for a Caucasian infant is now down to about nine months.

Agency vs. Private Adoption

Public and private adoption agencies provide vital pre-adoption as well as life-long post-adoption counseling services. It has been established that the availability of these specialized services is vital for the continuing well-being of the adoptive family. Most agencies also provide parent preparation classes to teach the new parents routine parenting skills. Adoption agencies routinely provide information concerning the medical and social history of the birth parents, copies of the infant’s birth and hospital records and his medical history at the time of adoption. Placement of the adoptee by a licensed adoption agency guarantees that the mother will not be able to again obtain rights to her child. New legislation helps deny the “absent” birth father rights to his child later in life. Independent (private) adoption is arranged directly between parents, attorney, or facilitator. Counseling services may or may not be provided, and are usually limited to what can be found in the community. The birth parents have a right to change their minds for a time after the adoption takes place (usually 90 days). The costs of independent adoption usually are higher than by agency adoption: public agency ($0-$500), private adoption agency ($4,000-$15,000), independent adoption ($10,000-$30,000). Some independent adoptions are reportedly higher than $30,000. An independent adoption may, in addition, cost the adoptive parents the birth mother’s food, shelter, travel, and medical expenses. California families adopted 6,215 children in 1994-95. Independent adoptions accounted for 1,850, public agencies accounted for 3,019, and 544 were completed by private agencies. In addition, there were 802 intercountry adoptions.

Intercountry Adoptions

Intercountry adoptions continue to pose problems. The laws regarding adoption are varied among the “sending” countries – these laws may change unexpectedly. Aspects of the U.S. Immigration Laws and the laws of each state also may serve as obstacles in the path of adoption of foreign-born children. No local subsidies are available to help deter the usually expensive adoption and upbringing costs for these children. The background importance of these children tends to be limited and clouded. Significant medical and immunization records may not be available. The true reasons that the child is available for adoption is often not known. Many of the “abandoned” children were actually placed in orphanages by parents solely to have their child adopted by Americans. The Chinese programs of “one child per family – preferably male” cloud the recent surge in the adoption of Chinese female infants. What are the ethics involved? The fees vary upward from $15,000 in addition to funds and time required for travel overseas.

Multi-ethnic Placements

Recent legislation has eliminated most legal barriers of multi-ethnic adoptions. Nearly a dozen studies consistently indicate that approximately 75% of transracially adopted preadolescent and younger children adjust well in their adoptive homes. The deleterious consequences of delayed placement are far more serious than those of transracial placement.

Adoption by Single Parents, Gays, Lesbians, and Relatives Legislation now prohibits discrimination against single parents, gays, lesbians or relatives (especially grandparents) in adoption practices. Each case is analyzed individually in light of the best interests of the child. Home studies of the prospective adoptive parents include the overall strength of these individuals and their environment. A close analysis is made to determine exactly what qualities are present in all of the people who will be in contact with the child.

Open Adoption

The past history of secrecy in adoption practices (attempting to make it impossible for the adoptee to find his or her birth parents) has shown that this policy could be detrimental to the well being of each member of the adoptive triangle. In addition, it is now quite easy for an interested and motivated adoptee to search for and locate his or her birth parents.

In view of these findings, new laws help create the open adoption, which provides for meetings between the birth parents and the adoptive parents prior to the birth of the child. They know each other as “real people” rather than as written information. The birth mother feels better about the adoption and can soon go on with her life without the pain and suffering associated with not knowing what has happened to her baby. The adoptive family can provide realistic and accurate information concerning his or her background when needed by the maturing adoptee. A post-adoption contract agreement may provide for an exchange of phone calls, information, pictures, etc. later in life. Open adoption may still remain slightly controversial, but experience has shown that many of the psychological problems observed under the earlier closed adoption era are disappearing.

International Child Health Committee (ICH)

The ICH Committee discussed monitoring legislation affecting minorities but decided that it could not take on those duties at this time.

The group discussed examples for the future. It was suggested to select one project to focus on for better success. Art Dover reviewed the Atlanta project with Brazil. That chapter has a health-building relationship with a community in Brazil.

The committee would like to identify one country or community that is disadvantaged to focus on international exchange with the use of journals, visits, texts, and Internet access. The committee would adopt another country as a form of medical exchange. Example: “The Friends of America Scholarship Program” noted to cover airfare for qualifying participants.

Highlights from Environmental Health Committee, 1998

Green Book

Mark Miller continues membership on the national Committee on Environmental Health. One of their major products is the upcoming professional manual, “Handbook of Pediatric Environmental Health.” The book will be broad ranging with topics including environmental history-taking, environmental tobacco smoke, air and water pollution, pesticides, lead, electromagnetic fields, noise, environmental justice, and many others. Projected publication date is April 1999.

Pediatric Environmental Health Conference

This national meeting will be held in San Francisco in June 1999. The major sponsor is the Children’s Environmental Health Network (CEHN) based in Emeryville, CA. It will provide clinicians and faculty important tools to facilitate incorporating pediatric environmental health issues into their practice and teaching. We have arranged for the Chapter to co-sponsor the conference, and urge the District to do so as well. The national AAP office has committed collaboration. We will continue to coordinate with CEHN and urge all pediatricians to consider attending.

Children’s Environmental Health Protection Act

We continue to support and monitor California’s AB 278 (Escutia), which will guarantee that environmental health standards protect infants and children, not just adults. It will require existing drinking water, ambient air quality, and toxic air contaminant standards to be reviewed and revised, if necessary. New standards must also consider and protect infants and children, and will require monitoring of air emissions near schools and daycare centers.

Food Quality Protection Act, 1996

This Act requires the US Environmental Protection Agency (EPA) to establish allowable levels of pesticide residues in food that are based on specific child safety data or, if no data exist, provide at least a 10-fold margin of safety to protect children (children’s protective health standard). Implementation of the Act to date has relied on forums dominated by industry representatives. It has not included formal representation from the AAP, which has led to failure to fully implement the children’s protective health standard. We submitted a resolution for the Chapter Forum calling for the AAP to monitor and formally participate in the implementation committees or forums for the Act. We will continue to monitor progress on this and other federal and state legislation impacting children’s health from environmental exposures.

Firearms Injury Prevention Conference

By Margaret M. McNamara

The issue of violence in our society has unfortunately made the headlines with great frequency in recent years, with all too many tragic accounts of the senseless loss of youthful lives from gunshot wounds. Nearly 36,000 Americans were killed by gunfire in 1995, 5300 of whom were children and adolescents. In California alone during that year, 4730 citizens were lost to firearm injuries including 843 children less than 20 years old. In an effort to address this complex and critical issue, the American Academy of Pediatrics gathered together a number of experts and other individuals committed to firearm injury prevention for a weekend of education and mobilization in the community. The Firearms Injury Prevention Training Conference, held in Chicago on March 14-15, 1998, provided an opportunity for 130 participants to learn about this issue from a public health perspective. A range of topics was covered from the epidemiology of firearm injuries and the developmental effects of gun violence on children to networking in the community and educating other health professionals. There was also significant attention given to the importance of asking about the presence of firearms in the child’s environment during routine health maintenance encounters. Just as we ask about car seats and bicycle helmets as part of our regular child safety screening, such questions can be posed in a non-threatening or non-judgmental way, thereby creating an opportunity for patient and parent education. Most parents do not know that having a firearm in the household increases the risk of homicide in the home threefold and the risk of suicide fivefold (Kellerman, 1992). Suggestions for anticipatory guidance were given with particular emphasis on removal of firearms from the household when possible or assuring that guns are unloaded and locked in a secure place. For families without a firearm in the household, this conversation gives the pediatrician an opportunity to encourage them to discuss this issue with other parents. If you are interested in more information on this important subject or would like to receive training in firearms injury prevention, please contact the AAP at (847) 228-5097 or e-mail to kidsdocs@aap.org.

Fetus and Newborn Committee Report

By Harry A. Ackley

The Chapter’s F&NB committee has representation on the National F&NB committee as well as the District IX Section on Perinatal Pediatrics and the California Association of Neonatologists (CAN). The activities and plans of these organizations are reviewed and input is returned to these organizations. Chapter members are encouraged to contact either of the Co-chairs, Harry Ackley (ackley@soml.com) and Carol Miller (cmiller@itsa.ucsf.edu). The committee hopes to have its own bulletin board up and running by this fall. This will be an experiment to see if we can function more effectively with a ‘home base’ on the Internet.

A focus of our activities the past year has been the evaluation and management of newborns in the week after birth. The past year saw national and state legislative success in terms of requiring insurance coverage for a mother’s and her infant’s hospitalization the first two days of life. (This doesn’t apply to the mothers and infants who are covered by MediCal. A two-day countdown starts on the mother’s arrival, not her delivery. This is only if she delivers in the hospital. If she doesn’t make it to the hospital in time and delivers in the parking lot, she and the baby will only be covered for a 24-hour observation period.)

It is the feeling of many of us on the committee that we pediatricians made our stand “a day too late.” We didn’t react effectively when the usual postpartum length of stay was reduced from four to three days and then from three to two days. We waited until it was reduced to one day. The problem is that the third and fourth days are when conditions such as hyperbilirubinemia, hypernatremic dehydration, and ductal dependent cardiovascular lesions most often become manifest. Our feeling is that there should be provision for an examination at 48 to 96 hours of age and follow-up examinations as indicated. Our committee has submitted a resolution for the chapter forum urging that this standard be adopted.

Job Announcements

There is an opening for the Title V Special Needs Director in Illinois,
connected with University of Chicago: 25,000 children. Please contact Phil
Ziring at (312) 633-6530.

Announcement

Pacific Southwest Regional Genetics Network is sponsoring a conference entitled Genetic Medicine: Into the 21^st Century – A Public and Professional Dialogue on August 22, 1998 at the Westin South Coast Plaza, Costa Mesa, CA.

For information contact Pamela Cohen (501) 540-2852.

How to Enhance Your Child’s Development

A National Pediatric Town Forum for Parents presented by the American Academy of Pediatrics and the Pediatric Institute of Johnson and Johnson

Saturday, October 17^th from 10:00 am to 1:00 pm

Place: Zeum, the new interactive art center for children at Yerba Buena Gardens (opening in September 1998), located between the San Francisco Marriott and the Moscone Convention Center. On-site child care services are available.

In Memorium

Kerry L. Spooner-Dean, a Candidate Fellow died tragically May 5. Spooner-Dean graduated from the Oakland Children’s Hospital residency program and had worked at the Contra Costa Regional Medical Center in Martinez. She was working to organize a mobile health clinic for the undeserved children of Oakland. A new Children’s Hospital award was created in her honor, recognizing a graduating resident who has advocated for children through community service and volunteerism. Contributions to Kerry’s memory can be sent to the Children’s Hospital Foundation, 747-52nd Street, Oakland, CA 94609.

For More Information

The complete text and links to related topics can be found at our Chapter website (http://www.aapca1.org). Many pediatric national and state activities and links can be found at the national Academy website (http://www.aap.org).

Position Available

The Committee on Pediatric Emergency and Critical Care Medicine is eager to recruit members interested in stengthening the continuum of emergency medical services for children. Contact Mary Rutherford, MD Children’s Hospital Oakland (510) 428-3259, Fax (510) 450-5836, e-mail cho.dr.mwr@cho.org or Jim Silva, MD 15466 Los Gatos Blvd. #109-169 Los Gatos 95032, (408) 358-0666 or e-mail mechpns@aol.com.

This page create 7/27/98 Last Updated 05/23/06