North Carolina Pediatric Society Spring Open Forum 2010

President Marian Earls and Vice President Karen Breach pay rapt attention.

Sheraton Imperial Hotel, Durham, NC

April 17, 2010

It’s sunny, 68 degrees in the morning with a high of 78. We live at the beach. Where would you go today? That’s right: it’s the perfect day to spend in a cavernous hotel meeting room!

What is the NCPS doing for you? Thank Christoph Diasio if you're now getting paid for cerumen removal during visits for other reasons. John Rusher is helping the state legislature understand what it is pediatricians do that pharmacists don't. Theresa Flynn is sitting down with the chiropractors' lobby to discuss why many pediatricians would like to see better safety and efficacy data before making widespread referrals to chiropractic. Graham Barden is marking up proposed legislation on a state vaccine pool to make sure it doesn't limit our options to buy vaccine on the private market. Kathleen Clarke-Pearson is appearing in vaccine-related public service announcements during highly-rated prime-time television. Executive Director Steve Shore is leveraging his long-term relationships with everyone in state government, garnering and managing enormous grants, and answering every random question from every pediatric practice all over the state.

Everyone takes the microphone and says hi:

Executive Director Steve Shore

Website revised, new passcodes are coming. Southeastern United Dairy Industry Association provided our lovely breakfast, replete with milk, cheese, and yogurt.

President Marian Earls

Please get involved! If you have an interest or a passion, let us know, and we'll make sure you have an opportunity to act.

Brandon Rector, North Carolina Immunization Branch

• May 1, Cervarix will be available to use, be sure and use the correct code.
• Prevnar 13 has replaced Prevnar 7, there is no more Prevnar 7 to be had. ACIP will end up recommending a catch-up dose of Prevnar 13 for children vaccinated on Prevnar 7.
• April 1st TDaP and Varicella #2 will be covered again under the Universal Vaccine Program.
• Go to ImmunizeNC.com to get the latest details on the program. Don't necessarily trust your vaccine reps, check out what they say on the website.
• Currently surveying providers on H1N1 vaccines program to try to improve future vaccine distribution efforts. H1N1 remains in circulation, will be covered in the 2010 seasonal vaccine.
• Rotarix had a viral contamination, but no safety issue, not a recall, just asking providers to suspend use of the vaccine for the moment. Don't throw it out!
• For any other questions, call (919) 707-5550

Tara Larson, Chief Clinical Operations Officer, Division of Medical Assistance

• New clients are entering into Medicaid system, people who have worked all their lives.
• New clients are sicker, have put off care as long as they can. Growth is 10% beyond what was anticipated.
• State revenues are falling, DMA is $250 million over budget, will have to be reduced.
• Major reductions
• Preferred drug list implemented March, 2010, utilizing prior authorization
• CCNC (Access III) has targeted initiatives to look at overprescribing and inappropriate prescribing in mental health.
• Personal Care Services are being reviewed for each individual, with a number of recipients being terminated for not meeting minimum eligibility requirements.
• All new personal care services clients are undergoing independent assessments of their needs.
• Personal Care Providers will undergo review, those who seem to be outliers will be audited.
• Case Management being overhauled, rethought.
• What does the future hold for DMA?
• Benchmarks are posted on the website for Financial, Program Integrity, and Provider/Recipient Services.
• DMA is taking over Health Choice July 1, 2010. New chief is Margaret Watts.
• Healthcare Reform will largely be implemented in 2014, although planning is occurring now.
• Level of federal poverty for coverage will be 133%
• Budget will be released in the next few days. DMA has been asked to produce options for budget reductions of anywhere from 3% to 12%. Options are not finalized yet, but some of them are rather drastic (such as eliminating all adult dental coverage). The only option not on the table is to reduce eligibility requirements.
• Likely cuts will be made in optional services, those that are not mandated by the federal government. For example, medication benefits and all of mental health are optional.
• New analytics software will be used to identify and eliminate fraud, may save up to 10%.
• Please call if you're having problems with enrollment. There have been some glitches.

Next the program chairs of all the pediatric residencies in the state spoke about the great things going on in their programs. It was too much to keep track of, suffice to say it's all good. No one said their match results were disappointing, so the future of pediatrics in NC would appear secure.

Jane Foy, MD (Chair, AAP Task Force On Mental Health) and John Diamond, MD

The Mental Health Competencies & Managing Behavior Medications In the Pediatric Office Setting

Jane Foy:

• 20% of youth have a mental disorder, but only a quarter of them receive care, and half of those terminate prematurely.
• Mental health system is underfunded, therefore focuses mainly on children with most severe conditions.
• Workforce of child mental health providers is inadequate, so primary care physicians step in to the gap.
• Primary care pediatricians report discomfort with mental health disorders other than ADHD. Lack of training, evidence, and payment also limit our ability to provide services.
• On the up side, primary care pediatricians have advantages including a longstanding therapeutic alliance, family-centered practice style, understanding of social and developmental aspects of the patient, experience coordinating children with special healthcare needs.
• North Carolina gives us an advantage in that we have an amazing Medicaid program. The first 26 mental health visits don't have to be case-managed. We can directly refer instead of using a third party agency.
• Look for supplement in Pediatrics in June and July of this year to help guide you in providing mental health practice to your patients.
• Competencies:
• Hope
• Empathy
• Language/Loyalty
• Permission/Partnership/Plan (H-E-L-P, get it?)
• Primary care of children with anxiety
• Identify children with the condition (may use PSC, SDQ). Need to assess functional status as well, which the SDQ does.
• Can utilize evidence based approach to therapy, using cognitive strategies, coping skills, exposure to causes of anxiety, and rewards for brave behavior.
• Formulate a plan, including good sleep hygiene, healthy lifestyle, medications, coordination of care with other providers, providing self-management tools for families.
• Anxiety: when to call a specialist
• Severe functional impairment
• Worsening or no progress
• Multiple symptoms in many domains
• Anxiety interferes with attending school
• Child very distressed (or parent)
• Co-morbidities involving shyness, anxiety, or behavior problems)
• PTSD (symptoms following some sort of trauma or loss)
• OCD and Panic Disorder symptoms
• Depression: primary care providers' role
• Identify patients with screening tool (PSC, SDQ, PHQ-A, beck)
• Screen for suicide (SADPERSONS)
• Early intervention in office including cognitive and coping strategies
• Depression: when to call the specialist
• Preadolescent child
• Depressed adolescent with prior suicide attempt
• Impaired functioning
• Substance abuse, psychosis.
• Worsening under primary care
• PTSD
• How to collaborate with Mental Health Provider
• Ideally integrate a provider in your practice
• Have a plan for communications, follow up

John Diamond, Child and Adolescent Psychiatry, Brody School of Medicine

• Diagnosis: self reports and screening instruments tend to have low sensitivity (lots of false negatives)
• So look at functional impairment as the most important sign that something is not right.
• Younger children often don't meet DSM-IV diagnostic criteria for depression.
• Kids often present with somatic complaints, sadness, anhedonia rather than weight loss and poor sleep.
• If you treat symptoms in isolation you end up with poly-pharmacy. You still have to get a good history.
• Getting kids off five drugs takes a long time, you want to move slowly. Chances are good they don't need all five.
• Child's self-report can be very useful in managing depression, anxiety in children. Parents and teachers don't always know what children are feeling. See the child alone, give him/her a chance to talk freely.
• Cognitive-Behavior-Therapy is strongly evidence based, may spare medications.
• Try getting child to therapist for CBT before the psychiatrist gets the child in.
• There is no evidence to support using two agents in the same class (don't give them Geodon AND Abilify).
• Not at all clear atypical antipsychotics work any better than the traditional antipsychotics.
• Drug response doesn't determine diagnosis. There is a huge placebo effect with the psychotropic drugs.
• Refer when child fails to respond to intervention
• The Great Bipolar Disorder Debate
• By DSM-IV late adolescents are susceptible to bipolar disorder, but diagnosis under that age is in great question: those kids don't grow up into bipolar adults.
• No evidence that mood stabilizers help kids diagnosed with Bipolar Disorder. Drugs are approved for true mania, not irritability.
• Mania is not a chronic condition. It is episodic. Kids don't tend to have episodes of mania, they just stay chronically over active.
• Most psychiatrists think these kids are actually ADHD kids on the severe end of the clinical spectrum. They may indeed be moody and very difficult to handle.
• There are several other diagnostic rubrics for these kids. By DSM-V there's likely to be a condition called Temper Dysregulation Disorder with Dysphoria.
• What to do instead? Behavioral management!
• Look at Antecedents, Behavior, Consequences (A-B-C, get it?)
• Don't believe there's no precipitant for a rage. There was something, whether or not the parent gets it.
• Consider all realms of development. Kids may go into a rage due to poor executive function, language skills, emotional regulation skills, or cognitive flexibility.
• Lots of parents think they're bipolar, but ask what they mean by that, because often they're not.

Jane Foy takes the floor again, this time as our District IV Vice Chairperson, with an update from the AAP

• Be aware the American College Of Pediatricians, a splinter group of anti-gay pediatricians, has sent a letter to school superintendents about homosexual students full of misinformation about how they have a disease/lifestyle choice that can be cured. The AAP has responded with an evidence-based statement of our principles. (I can add that Dr. Francis Collins, upset about being mis-quoted in the letter, has also sent a correction letter under separate cover).
• The Academy is satisfied if not thrilled with the outcome of the healthcare reform bill. We do see some significant advantages accruing to our members, including loan forgiveness and increased numbers of insured children.
• There are states where Nurse Practitioner-led practices are trying to gain medical home recognition. This has been controversial where it has come up (Pennsylvania).

Awards Presentation

There were two people who couldn't come to the NCPS Annual Meeting for 2009, but they were able to show up today to finally receive their well-deserved awards.

Tom Vitaglione Child Health Advocacy Award to Pam Silberman, JD, DrPH, President & CEO of the North Carolina Institute of Medicine

Good For Kids Award to Jeffrey Simms, MSPH, MDiv, UNC Gillings Schools of Global Public Health

Gerri Mattson, MD, DPH

updates from the Children and Youth Branch, NC Division of Public Health

• Don't think that budget cuts have kept the NC Division of Public Health from being very ambitious in serving kids' needs.
• Title V/Maternal and Child Health Program
• Responsibility: improve health of all children in NC, assure access to quality child health services, increase the number of low income children receiving health assessments and diagnosis/treatment services. These missions overlap the missions of the AAP.
• Newborn screening started in 1965, mass spectrometry since 1999, Newborn CF since 2009.
• Have diagnosed 29 new cases of CF from April, 2009 to April, 2010 out of 522 abnormal screens.
• If you can, schedule an appointment to review abnormal results with parents to reduce anxiety.
• There are regional genetic counselors throughout the state
• Diagnosis will have to be made at an accredited cystic fibrosis center.
• Make sure the center knows why you're sending the child: what did the screen show?
• CFTR related metabolic syndrome, at risk for CF later in life, have identified 8 so far with the screening program.
• Tandem mass spectrometry: finds 30 different diagnoses. Screened over 126K children in 2009, found 6 with MCADD, 7 with PKU, 1 with MSUD, 3 with 3-MCCD
• Coordinator makes sure children get follow up testing through their primary care physicians
• State program provides special metabolic formulas for children who require them.
• Early hearing Detection and Intervention Program
• Rescreening should be performed at 1 month if initial screen not normal. By 3 months of age children with abnormal hearing re-screens should see an audiologist, and by 6 months they should be fitted for hearing aids.
• Hearing screening needs to be done for children with risk factors q 6 months
• Investing in Evidence-Based Programs in NC
• Nurse-Family Partnership: home visiting for first time, low income parents starting prenatally. Outcomes are very good.
• Every Child Succeeds:
• Evidence-based parenting programs, Strengthening Families Program, Incredible Years Program
• LAUNCH: Linking Actions for Unmet Needs in Children's Health
• Children and Youth With Special Healthcare Needs
• Links children enrolled in Social Security Disability Insurance with local health departments for early intervention services or child health coordination up to age 5
• For children over age linked to CSHCN Help Line, referred to Sickle Cell Disease Program, Hearing Impairment program.
• NC Office on Disability and Health (ODH)
• Parnership with Frank Porter Graham and the Children and Youth Branch
• Helps with transition from pediatric to adult health care for older children with special needs.
• Innovative Approaches: Improving Systems of Care for Children and Youth with Special Health Care needs. Fostering community strategies for effectively caring for children and youth with special healthcare needs. Figure out what works best, then disseminate those practices.
• Kindergarten Health Assessment (should have 1/08 in the corner).
• Don't have to be blue
• Get them at nchealthyschools.org and ncpeds.org
• Healthy and Ready to Learn Project. Connects children with health insurance if they don't have it.
• Access to Care
• Several organizations are helping to identify needs: Smart Start, Juvenile Justice, Schools, Healthcare providers
• For newborn screens call Lara Percenti at (919) 707-5600
• Genetic Counselors (919) 707-5600
• Speech/language or Auditory Consultants (919) 707-5600 or www.ncnewbornhearing.org
• CSHCN Help Line (800) 737-3028
• School Health Unit (919) 707-5671

Peter Morris, MD, MPH, MDiv

NCPS Foundation Report - CHIPRA, Foster Care, Maintenance of Certification, and the Role Of the Chapter In Assisting Pediatricians

• Obesity project connects children with YMCA, nutritional counseling, and primary care providers
• Medical Home for Children in Foster Care. These kids are at very high risk. Working on finding stable medical homes, implementing best practices to provide them the best possible care.
• Reach Out And Read. The more books there are in the home, the better kids do in school. This puts books in homes.
• CHIPRA outreach and enrollment. Uses the kindergarten health assessment form to identify children who have no insurance. So make sure your parents actually fill out that part of the form when they're in your office!
• The Foundation's money is largely based on grants. There is also an endowment supplied by the North Carolina Pediatric Society that pays for staff and logistics.
• So far we don't have a big event as a fundraiser.

John Rusher, MD, JD

• We have a PAC!
• But it needs MONEY!
• Please invest in our ability to look after your interests by giving to the PAC.

What's All the Fuss About the NCQA Primary Care Patient Centered Medical Home? Getting Acquainted and Getting Started

Kelly Goonan, MPH, CPHQ, Special Projects Manager, Gulford Child Health

• Application process is complicated, far from user-friendly.
• The model of care is centered on the personal physician, physician-directed practice, whole person orientation, and coordinated care
• Nine standards of patient care, 30 elements in all, ten of these elements are mandatory to qualify.
• There are three levels of health information technology you can use, and you can get qualified with as little as an electronic practice management system and paper records. At the advanced level you'd be able to electronically interface with other entities.
• Four elements require medical record review, some of them being Must Pass elements.
• You'll need to choose three conditions in your practice to be evaluated
• Chart review will be the last 36 patients you saw.

Christoph Diasio, MD, FAAP

• This system is perfectly designed for adult medicine. It would not appear anyone has really thought about applying it to kids. Getting answers from NCQA is not at all easy.
• Bottom Line: Blue Cross/Blue Shield will pay you more if you do this. Substantially more.
• You have to do PCMH
• You have to learn cultural sensitivity online
• You have to use e-prescribe
• Could mean an extra $20 to $40 for each 99213 visit under Blue Cross Blue Shield. You do the math.
• The training document on the NCQA website will be your friend.
• What conditions are you going to choose to audit?
• You can look at your top three codes
• Asthma, ADHD, and obesity are the obvious conditions to choose in pediatrics.
• You will have to demonstrate to someone not standing in your office how it is you use your system to provide care.
• It's worth it to sign up for the $75 self-assessment tool at the outset to get a sense of what you're going to need to do.
• Get to know your Blue Cross representative
• Build tools/templates to help you track what you do for people

That's it for this session, but please consider attending the NCPS Annual Meeting in Myrtle Beach July 30 to August 1. I have it on good authority the Committee On Media will be presenting a truly amazing workshop on understanding and leveraging digital media...