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.
Their expanding ranks and critical developments nationwide affecting hospital pediatric units and availability of pediatric services now makes discussion about the importance and future of the role unavoidable.
Pediatric services have never been considered financially impactful. 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 hospitals close their pediatric units and cut back on their outpatient services, it’s clear that getting paid less than expected for services provided is even worse than being paid what’s expected.
While pediatric medicine is advancing year over year, our nation’s hospitals’ capability to provide this level of care is dwindling due to insufficient payment.
There is no side-by-side comparison with adult counterparts, when it comes to many aspects of patient care. From clinical presentation and clinical trials to treatment modalities and Food and Drug Administration- (FDA)-approved pharmaceuticals, there often are stark differences – or even a true lack of comparative data. One impactful example 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, there often is nothing that even mentions major treatment pathways usually only seen in pediatrics.
Additionally, it is very common for payer medical directors to misidentify the major factors of a case and try to fit complicated diagnoses into simplistic conditions. Hospitals that have pediatric departments 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 also having staff with the ability to explain the reasoning to a payer medical director who lacks this expertise.
Top-hitting diagnoses in hospital pediatrics are not really all that 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, as completely illustrated in the documentation, captured by the coders, and appreciated by the payers.
One of the key roles physician advisors play is to maintain the financial health of hospitals so they can maintain the physical health of the communities they serve. It’s high time health systems recognize the pediatric patients 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’ll all rely on and be inspired by for generations to come.