In the
fiscal fight over health care costs, pediatricians are on the chopping block.
In hospitals and clinics across the country, pediatricians are being laid off
in droves, leaving the clinical burden to mid-level providers, family
physicians, and emergency room doctors. These decisions are being made by suits
over scrubs, and they are putting patients at risk.
Recently,
three pediatric facilities closed in Dallas when MD Medical Group acquired
Children's Health Medical Center and consolidated pediatric operations,
terminating twenty-seven pediatricians. In April, Maryland's
MedStar Health announced the immediate closure of inpatient pediatrics and the pediatric
emergency department at Franklin Square Medical Center. Last October, Boone
Hospital Center in Missouri announced it was closing its pediatrics unit. Last September,
Pottstown Memorial Medical Center closed its inpatient pediatric unit. And last
summer, Mount Sinai hospital in Chicago ended its pediatric services.
“Pediatric
hospital care is less available than it used to be..." said senior author Dr. Michael McManus, a
pediatrician and professor at Harvard Medical School. "Hospitals are
paring back on certain lines of business, and pediatrics is one I think they
look at very closely..." said Allan Baumgarten, an independent health care
financial analyst.
What's
driving this phenomenon? It's largely an attempt for providers to maintain --
or in some cases, maximize -- profitability on a growing share of Medicaid
patients. There have been more than 22 million new Medicaid enrollees since the
beginning of 2010, when the Affordable Care Act, which greatly expanded the
program, was passed. One in two births in the country is now paid for by
Medicaid. Yet Medicaid's reimbursement rate is only about half that of privately-insured patients. As a
result, hospital executives are looking to cut labor costs, which make up about
60 percent of hospitals' operating costs.
Faced with
these dynamics, many providers, including the prestigious Mayo Clinic, have selectively restricted or refused to treat Medicaid patients. Roughly half of doctors are
unwilling to treat new Medicaid patients because they are not profitable. But
this approach does little more than foist Medicaid patients onto already
overburdened emergency rooms.
Laying
off pediatricians in favor of NPs and emergency room physicians is an attempt
to monetize these patients. But this is also problematic.
Most
importantly, it puts patients at risk of substandard care. NPs require four
years of college and a thousand hours of clinical experience -- significantly
less than the eight years of college, three years of residency, and 20,000 clinical hours needed by physicians. While NPs
can do a wonderful job caring for many problems, they receive far less rigorous
training than even medical students, who would never be allowed to treat any
patients unsupervised. Worryingly, there are also signs that NP training is becoming watered down by
assembly line programs.
Of
course emergency room and family practice doctors will pick up the slack to
some degree. But they also don't have the same familiarity or training
necessary to meet the unique needs of children, whose physiology, treatment,
and responses are often different. In our decades of clinical practice, adult
physicians universally recognize the need for pediatric patients to receive
care from the doctors who are specially trained to treat them.
Consider
an example, which is representative of many other similar experiences
throughout our careers. Dr. Al-Agba was able to catch the subtle signs of an
unusual condition in an ill toddler during flu season. She was able to
determine that the patient had ingested multiple small magnets, which were then
attracted to each other and connected inside her intestines, which could have
been fatal. She was immediately operated on and recovered uneventfully.
Missing
subtle signs in pediatric patients can lead to deadly consequences. Such cases
demonstrate that all children, regardless of income, deserve access to adequate
pediatric care.
Is
there a solution to this problem short of comprehensive health care reform?
Potentially. Instead of looking to pediatricians and other specialty physicians
to cut labor costs, providers should look to cut administrative jobs, which
have expanded to the point where there are now ten times as many administrators as physicians. Many of these
bureaucratic positions offer little-to-no value to the patient or the doctor.
In fact, they often impede physician productivity, reducing
profitability.
But
for now, pediatricians must speak for children's right to access the physicians
specially trained to care for them. Because it is increasingly clear that
health care executives will not.
Niran
Al-Agba is a pediatrician in solo practice
and a board member of Practicing Physicians of America. Marion Mass
is a pediatrician and co-founder of Practicing Physicians of America.
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