Toward a Quality Workforce

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REFERENCES

1. Osborne L. Sample error.The New Republic.February 1, 1999 2. Menand L.The Metaphysical Club.New York, NY: Farrar, Straus and

Giroux; 2001

3. Youdon WJ. Sets of three measurements.Scientific Monthly. 1953;76: 143–147

4. Pearson ES. Duplicate measurements.Biometrika. 1932;24:404 – 406 5. Weiss FJ. Sets of three measurements [letter].Scientific Monthly. 1954;

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6. Salsburg D.The Lady Tasting Tea. How Statistics Revolutionized Science in the Twentieth Century.San Francisco, CA: WA Freeman; 2001

The Effect of Medicaid

Participation by Private and Safety

Net Pediatricians on Incremental

Expansion of Coverage for

Children

ABBREVIATION. SCHIP, State Children’s Health Insurance Pro-gram.

E

xpansions in Medicaid eligibility over the past 10 years and the creation of Title XXI of the Social Security Act, State Children’s Health In-surance Program (SCHIP) have resulted in coverage for many children who would not otherwise be cov-ered. The article by Tang et al1_{in this month’s issue}

of Pediatrics electronic pages titled “Uninsured Chil-dren: How We Count Matters” compares Medicaid participation by private and safety net pediatricians in 1993 and in 2000 and speaks to some important factors underlying how well Medicaid and SCHIP coverage has translated into access to quality pedi-atric care.

Tang et al report that: 1) the proportion of pedia-tricians accepting all Medicaid patients increased sharply between 1993 and 2000, and 2) those who accepted all Medicaid patients had substantially higher Medicaid caseloads. However, these changes did not occur evenly across private and safety net settings. The strong association between pediatri-cians’ willingness to see all Medicaid patients and their Medicaid caseloads was mitigated in safety net settings, suggesting that some safety net providers with the highest Medicaid caseloads may have to turn away new Medicaid patients as they reach ca-pacity limits.2_{Even then, the study documented that}

in 2000, Medicaid caseloads in safety net settings remained disproportionately high, compared with private office settings.

These results are important reminders for policy-makers to pay special attention to recruiting and retaining private pediatricians as Medicaid and

SCHIP providers. When Medicaid children are dis-proportionately seen in the safety net, the legal statue to provide equal access to Medicaid and privately insured children cannot be fulfilled without contin-ued improvement in private provider participation. More importantly, this study documented much greater potential among private than safety net pe-diatricians to increase their capacity to serve Medic-aid patients. For MedicMedic-aid and SCHIP to deliver on their promise of health care to existing and new enrollees, this report should be considered with other reports that have identified barriers for pedia-trician participation in Medicaid: low reimburse-ment, paperwork, and payment practices.2,3 _{At a}

time when tightening state budgets threaten to un-dermine Medicaid and SCHIP provider payments, the challenge to recruit and retain private providers must be carefully considered, lest Medicaid and SCHIP coverage will lose its capacity to deliver promised care, and access to pediatric care in main-stream settings will once again elude Medicaid chil-dren.

Richard L. Bucciarelli, MD, FAAP

Chair, AAP Committee on Federal Governmental Affairs

University of Florida Gainesville, FL 32611-3157

REFERENCES

1. Tang S-fS, Olson LM, Yudkowsky BK. Uninsured children: how we count matters.Pediatrics.2003;112:e168 – e173

2. Cohen JW, Cunningham PJ. Medicaid physician fee levels and chil-dren’s access to care.Health Aff.1995;Spring:255–262

3. Berman S, Dolins J, Tang S-f, Yudkowsky B. Factors that influence the willingness of private primary care pediatricians to accept more Med-icaid patients.Pediatrics. 2002;110:239 –248

Toward a Quality Workforce

T

he Committee on Pediatric Workforce pub-lished a policy statement in the February 2003 issue of Pediatricsthat calls for high standards and clear accountability in the care of children.1_{In a}

time when adequate care is threatened because of deteriorating economic resources and fragmented ac-cess, and when high-quality and optimal outcomes are increasingly sought by all patients, payors, and providers, a call for excellence is timely and appro-priate. The proposed methods to achieve these wor-thy goals are, however, deeply flawed, particularly as concerns nurse practitioners.

Team approaches to pediatric care are fundamen-tal to providing the seamless, comprehensive care required by children and their families. There may be no other group of individuals so in need of the broad

Received for publication Mar 5, 2003; accepted Mar 5, 2003.

Address correspondence to Richard L. Bucciarelli, MD, FAAP, University of Florida, 229 Tigert Hall, Box 113157, Gainesville, FL 32611-3157. E-mail: [email protected]

Received for publication Apr 16, 2003; accepted May 28, 2003.

Address correspondence to Mary O. Mundinger, DrPH, Columbia Univer-sity School of Nursing, 630 W 168 St, Rm 139, New York, NY 10032. E-mail: [email protected]

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scope of care that only a team of diverse specialists can provide. A child’s health needs change as he grows and experiences challenges to optimal well-being; illness and disease are only a small part of those challenges. Therefore, the disease specialist— the pediatrician—merits leadership of the team only when disease is the major concern. At other times, it may be the nurse practitioner or the psychologist or learning specialist who directs the team. And per-haps most important, it may sometimes be the par-ent.

The premise that all non-physician providers can be lumped together leads to several misinterpreta-tions. Nurse practitioners are independently licensed and are distinctive in education and in scope of practice from other disciplines, including medicine. Whereas nursing and medicine have a great deal of overlap (diagnosis and treatment of initially unde-tected disease or ongoing care of chronic illness), nurse practitioners have additional intensive educa-tion in individual risk reduceduca-tion and preveneduca-tion strategies, health promotion, and health education, and they have significant supervised clinical training in community sites, schools, long-term care settings, and home care, as well as conventional hospital and office-based practices. In contrast, pediatric resi-dency training focuses primarily on hospital care of acute and serious illnesses.

The American Academy of Pediatrics has long rec-ommended that pediatricians include prevention, early detection, and management of behavioral, de-velopmental, and social problems in the context of primary care.2– 4_{Although epidemiologic studies}

in-dicate that 13% to 20% of all children have an emo-tional or behavioral problem, many of these condi-tions remain undetected and undertreated, because they are underidentified, underdiagnosed, and un-derreferred in pediatric primary care.5–7 _{The risks}

and long-term consequences of the psychosocial morbidities are significant. Interventions for these complex and multifactorial problems require exper-tise that goes beyond the medical model of pediatric care. The coordination of care for children requires input and intervention from multiple sources and in multiple settings. This cannot easily be accomplished in the brief well care encounters of conventional primary care delivered by pediatricians. Children require a primary care provider who is experienced in and understands family dysfunction, develop-mental, behavioral and emotional problems, school stress, and inadequate nutrition. Nurse practitioners have developed an early warning system because of education and training in all of these aspects of care. Unless a child is experiencing life-threatening, unsta-ble, or complex illness, the nurse practitioner may be the provider of choice for the pediatric team.

The authors of the policy statement are right to raise concerns about pediatricians’ increased liability when they assume supervisory oversight. Whereas pediatricians see more complex, life-threatening con-ditions, which raise their potential for bad outcomes, nurse practitioners generally practice at the gateway to care, often making decisions about subtle cues regarding the need for specialist interventions. Each

group—physicians and nurse practitioners—faces its own unique challenges. Nurse practitioners are in-dependently licensed and authorized to provide care within state regulations, and they are independently liable for their practice. Even in the 6 states where physician supervision is required, nurse practitio-ners cannot relinquish the responsibility inherent in their licensure. It would be folly to impose physician supervision where none is called for.

Nurse practitioners carry their own liability insur-ance. Their premiums, as for physicians, are based on malpractice experience of the specialty. Nurse prac-titioner premiums are only a fraction of the amount physicians in the same specialty must pay, and the difference is attributable to the much lower incidence of malpractice claims against nurse practitioners. With over 35 years of nurse practitioner practice— and those in pediatric primary care were the very first—there is no evidence of claims against nurse practitioners even approaching those of physicians. Malpractice insurance premiums are a valid national indicator of the potential harm that can accrue to patients from health care practitioners, and in every nurse practitioner/physician specialty the claims against nurse practitioners are tiny compared with those for physicians.

Contrary to the AAP policy statement, it is ques-tionable that non-pediatric physicians are more qual-ified to care for children than pediatric nurse practi-tioners. Education for non-pediatric physicians is often limited to 1-month clerkships in pediatric med-icine during the third year of medical school. The only non-pediatric physicians who usually have ad-ditional pediatric experience are those in family prac-tice. However, their residency training encompasses

⬍1 semester of pediatric care, and most of that oc-curs in the acute care setting. Pediatric nurse practi-tioners, by distinction, have 5 semesters of pediatric training, mostly in ambulatory settings.

Even within pediatric primary care, the pediatric nurse practitioner has value-added skills and a per-spective different from a pediatrician’s. Conven-tional education for a pediatric nurse practitioner is 6 years— 4 to earn the bachelor of science (with pedi-atric hospital and home care experiences and family and community and developmental psychology training), as well as 2 years of pediatric primary care. Increasingly, patients seek and need the skills that differentiate nurse practitioners from physicians. The increased prevalence of chronic illness in children requires family and community-based approaches, and prevention and education are crucial to good control. The number and vulnerability of the under-served are growing in crisis proportions, and nurse practitioners have served this population with dis-tinction and excellence since the inception of the nurse practitioner role in 1965.8 –10

The authors of the policy statement cite the serious inadequacy of pediatrician delivered care to these populations, showing that⬍40% can be served with today’s pediatrician resource. Nurse practitioners practicing independently can fill the gap— both geo-graphically and numerically—when pediatric service access is inadequate. If nurse practitioners were

lim-COMMENTARIES 417

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ited to working under physician direction or within physician-led teams, pediatric patients would be de-nied full and open access to the quality care they need and want. And nurse practitioners do more than substitute for conventional care; they bring a style of engagement and patient empowerment that is particularly valuable in the advancement of self care and wellness. So important has been the nurse practitioner resource for the underserved that the federal government mandated that all state Medicaid programs must authorize pediatric nurse practitio-ners and family nurse practitiopractitio-ners for direct pay-ment for primary care services.

Medicaid is not the only area where broad accep-tance of nurse practitioners is evident. In the Bal-anced Budget Act of 1997, Medicare authorized di-rect payment to nurse practitioners for all Part B services in any site.

Commercial insurers also have recognized the value and quality of nurse practitioners as providers of primary care. Faculty nurse practitioners at Co-lumbia University School of Nursing are included as full primary care providers in the same contracts Columbia physicians hold, and the fees are identical. The 36 nurse practitioners credentialed by the school of nursing and medical departments have admitting privileges to the medical center hospital and are valued colleagues of the Columbia physicians. There are no supervisory relationships, but teamwork is brilliantly apparent, including the relationships de-veloped in pediatrics. Contrary to the citations in the American Academy of Pediatrics policy statements, these Columbia nurse practitioners were found to be equivalent to physicians in terms of outcomes and patient satisfaction in a randomized trial where the nurse practitioners were inindependent, notsupervised

practice.11

The nursing community is in agreement with the American Academy of Pediatrics in their call for high standards, adequate education, and clear account-ability. Columbia University School of Nursing is currently engaged in a national initiative to advance the formal training of nurse practitioners as they assume more independent and full scope practices. A clinical doctorate is long overdue for the nursing profession.

Columbia University School of Nursing was the first to require formal courses in genetics and evi-dence-based practice for all its nurse practitioner students. Pediatric medicine is changing its resi-dency training to incorporate more developmental and behavioral aspects of pediatric care, but this concentration, along with the community and family focus, have been the core of pediatric nurse practi-tioner training for over 35 years; this educational training has provided a large and reliable profes-sional resource for children and families. To negate that resource and suggest that the great majority of pediatricians carry out this broad scope of practice in a better way than nurse practitioners is contrary to fact.

Telemedicine is a tool we can all benefit from, but imposing it as a supervisory method when none is needed, or requiring a new level of physician

over-sight when nurse practitioners have a long history of unblemished excellence is wasteful and inappropri-ate. The literature speaks unequivocally about nurse practitioner competence; the children need us all.

Mary O. Mundinger, DrPH

Columbia University School of Nursing New York, NY, 10032

REFERENCES

1. American Academy of Pediatrics, Committee on Pediatric Workforce. Scope of practice issues in the delivery of pediatric health care. Pediat-rics.2003;111:426 – 435

2. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care.Pediatrics.

2001;108:1227–1230

3. Brandenberg NA, Friedman RM, Silver SE. The epidemiology of child-hood psychiatric disorders: prevalence findings from recent studies.

J Am Acad Child Adolesc Psychiatry. 1990;29:76 – 83

4. United States Department of Health and Human Services, Center for Mental Health Services. CMHS launches national campaign to increase awareness of children’s mental health problems.Psychiatr Serv.1996;47: 441

5. Lavigne JV, Binns HJ, Christoffel KK, et al. Behavioral and emotional problems among preschool children in pediatric primary care: preva-lence and pediatricians’ recognition. Pediatric Practice Research Group.

Pediatrics. 1993;91:649 – 655

6. Stiffman AR, Chen YW, Elze D, Dore P, Cheng LC. Adolescents’ and providers’ perspectives on the need for and use of mental health ser-vices.J Adolesc Health.1997;21:335–342

7. Forrest CB, Glade GB, Baker AE, Bocian AB, Kang M, Starfield B. The pediatric primary-specialty care interface: how pediatricians refer chil-dren and adolescents to specialty care.Arch Pediatr Adolesc Med.1999; 153:705–714

8. Brown SA, Grimes DE. A meta-analysis of nurse practitioners and nurse midwives involved in primary care.Nurse Res. 1995;44:332–339 9. US Congress. Office of Technology Assessment. Nurse Practitioners,

Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis.

Washington, DC: US Government Printing Office; 1986. Health Tech-nology Case Study 37

10. Safriet BJ. Health care dollars and regulatory sense.Yale J Regul. 1992; 9:417– 488

11. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial.

JAMA. 2000;283:59 – 68

Toward a Quality Workforce:

Setting the Record Straight

A

ssuring quality health care to all children is a challenge to the entire medical community. Working collaboratively in teams is a time-tested approach that brings together the expertise of diverse individuals. Intrinsic in the team concept is that health care is not reduced to an either-or-ap-proach, but is all-inclusive, taking into account the physical, emotional, developmental, cultural, and psychosocial needs of the child and the family.

The policy statement, “Scope of Practice Issues in

Received for publication Apr 28, 2003; accepted Jun 3, 2003.

Address correspondence to Carol D. Berkowitz, MD, Harbor-University of California Los Angeles Medical Center, 1000 W Carson St, Box 437, Tor-rance, CA 90509. E-mail: [email protected]

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DOI: 10.1542/peds.112.2.416-a

2003;112;416

Pediatrics

Mary O. Mundinger

Toward a Quality Workforce

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DOI: 10.1542/peds.112.2.416-a

2003;112;416

Pediatrics

Mary O. Mundinger

Toward a Quality Workforce

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