Mr. Obama Has Some Reading to Do

By Suzanne Berman, MD

The Obama administration recently announced plans to use a series of “mystery shoppers” to see whether it’s true that patients with Medicaid have problems getting appointments with doctors.

This isn’t just idle curiosity; Medicaid patients are supposed to get care equal to privately-insured individuals. The equal access provision of the Medicaid Act, 42 U.S.C. § 1396a(a)(30)(A), states that:

“A state plan for medical assistance must . . . provide such methods and procedures relating to the utilization of and the payment for, care and services available under the plan to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population.”

While I’m pleased to see that someone at the federal level appears to be paying attention to Medicaid access problems, this initiative wasn’t all that novel, and in fact seems downright redundant: for years, doctors have been documenting the difficulties with Medicaid access in peer-reviewed medical journals.

About ten years ago, pediatrician and AAP president Steve Berman published a study that documented that, nationally, children with Medicaid indeed had much poorer access to private pediatricians than their privately-insured counterparts. Based an excellent cross-sectional survey of private pediatricians nationwide, its results were impressive for their comprehensiveness; the conclusion wasn’t that surprising or novel, even in 2002.

Since then, the Medicaid/private insurance access to appointments disparity has been studied broadly, again and again – with strikingly similar results every time. Just a few of the studies conducted within the past decade (many of which have even used the “mystery shopper” technique) include evaluation of:

Even yours truly at Survivor: Pediatrics compiled a survey of Tennessee pediatricians showing that Medicaid-insured children in Tennessee do not have the access to pediatricians enjoyed by their privately-insured counterparts.

A few days after its announcement, the Obama administration announced that it was cancelling its mystery shopper initiative. Hopefully, someone decided that re-inventing the wheel wasn’t necessary after all.

Suzanne Berman is a practicing general pediatrician in rural Tennessee. Her study of Medicaid access was supported by a grant from the American Academy of Pediatrics’ Community Access to Child Health (CATCH) program.


Schoolteachers Are Awesome – School Health Policies, Less So

Schoolteachers are awesome.

They exhibit saintlike patience and calm with tantrums, vomit, and playground injuries. They watch child development in real-time and understand intuitively that what is normal for one child might not be normal for another. And they genuinely love children, which makes them good parent material. It’s probably not surprising that schoolteacher moms and dads top the lists of my favorite families in our practice.

I also have a lot of respect for schoolteachers because they seem to deal with many of the same frustrations that pediatricians struggle with. Teachers, like pediatricians, find that parents can be a child’s biggest advocate in life, but also parents can be a child’s biggest barrier to success. Teachers also seem perpetually consumed with meetings, regulations, and paperwork, with less and less time given to one-on-one classroom care each year. Teachers also suffer the consequences of unfunded mandates.

It seems a no-brainer that pediatricians and teachers ought to be allies for children’s well being.

So why do pediatricians seem to be at odds with the school system so much of the time?

My colleague Dr. Fierstein posted recently on Survivor Pediatrics the absurdity of needing a doctor’s note to apply sunscreen in New York schools. Her plaintive appeal to common sense seems a no-brainer and started me thinking about other ways that our public school systems suck health care dollars.

The cost of school notes.

In most school systems, children are allowed a certain number of “mommy excuses” per semester or year. However, children who exceed this threshold must have their absences excused by a doctor’s note; parents without doctors’ notes face truancy charges. Consequently, parents want to collect a doctor’s note each time their child is sick so they can save their few “Get Out of School Free” cards for emergencies.

Some doctors are OK with issuing these notes by telephone. Certainly, there is still a cost to this; someone has to answer the phone, get the information, and fax a note to the school. As I’ve said before,  I’m hesitant to certify over the phone an illness that I haven’t personally evaluated.

In this case, my main reason for refusing to do doctor notes over the phone is that it adds nothing. If a mother calls the school and says her child is sick, the school won’t accept it. But if a mother calls me and says her child is sick, and I write a note to the school saying “Mom says her child is sick,” that somehow becomes acceptable documentation for the school.

The school expects me to take mom’s word for it but is unwilling to do so itself more than five times per semester.

This neatly passes the buck (or should I say, the bucks) to me, the de facto attendance secretary. And an MD is a pretty expensive attendance secretary. So our policy is: if you’re sick enough to miss school and need my note, you’re sick enough to come in.

In these cases, parents know their children have colds, stomach viruses, and other mild self-limited illnesses which require kids to miss a day or two of school. There’s no diagnostic dilemma, no prescription needed, no particular question that needs my expert opinion. Nonetheless, I estimate that at least 15% of school-aged children coming to my office for a sick complaint are doing so simply to get a school note.

Direct medical costs of getting school notes

What does it cost the health care system to provide these kinds of notes for a school system? Here’s a very rough estimate.

· Number of sick visits to our pediatric practice of school-age kids between August 2009 and May 2010: 5700

· Percent of visits just for school notes: 15% (low estimate)

· Cost per sick visit of this type: $50 (low estimate)

· Total annual cost: $42,750+ just for patients of our practice.

This would more than cover the salary and benefits of a full-time county schools employee, who could monitor attendance and follow up by telephone or home visits to frequent absentees.

If our practice is representative, Tennesseans are spending at least $14 million per year in private and Medicaid health dollars to fund school notes. (This doesn’t, of course, account for the indirect costs to parents, such as transportation to and from my office.)

I suspect that if school systems needed to foot the bill for these office visits, they would quickly find more cost-effective ways to monitor attendance. And I’m not sure we pediatricians have done enough to discourage these kinds of school policies; as you can see, this fairly reliable revenue stream might present a conflict of interest. But it’s not a good use of limited health care dollars. Let’s save the doctor-issued school notes for when there’s really a question for the doctor – like, “Is Kaitlyn’s rash contagious, or can she go back to school?” or “When can Chad return to football after his concussion?” Something may be able to subsidize a cash-strapped educational system, but it shouldn’t be the health care system.

Suzanne Berman is a general pediatrician in Tennessee. Both she and her son, Simon, think that his third grade teacher, Mrs. Hutchings, is really awesome.