New High Risk Child RSV Prevention Guidelines

Today the American Academy of Pediatrics published a new policy statement, Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.

photo source: Shutterstock

This very long title is basically the roadmap that physicians should follow when deciding which infants and young children would benefit from a vaccine to prevent the virus commonly known as RSV (Respiratory Syncytial Virus). RSV is a very common virus, affecting nearly all children by 2 years of age. Reinfection seasonally (late fall to early spring) is also common. It typically causes common cold symptoms and ear infections, but in infants it can lead to bronchiolitis, a condition where there is wheezing and difficulty breathing. Most people who are infected can be treated with home therapies, but some infants require hospitalization for oxygen or iv fluids. The majority of hospitalizations occur during an infant's first year of life and are among otherwise healthy, term babies, not premature or otherwise at risk babies. This is likely due to the fact that parents of at risk infants tend to be much more cautious and aware of infection prevention and tend to avoid situations that could increase risks, such as daycare. It would be impractical for most working parents to stay home with their children the first winter, and the overall risk of hospitalization of a healthy baby is still very low despite the use of daycare. The virus is spread through close contact with others who have the virus and it can live on contaminated surfaces for several hours. Unfortunately since it only produces mild symptoms in older children and adults and can be spread before symptoms develop, caution must be taken throughout the cold and flu season to avoid spreading germs.

The palivizumab vaccine is commonly called Synagis. It has been used since 1998 to prevent RSV infection in at risk children ~ those whose lungs are underdeveloped due to prematurity, those with significant heart defects, and other risk factors. Due to cost and needs analysis, it has never been recommended for routine use in otherwise healthy children. When deciding which children will benefit from the vaccine, experts review its effectiveness, drug resistance, and cost analysis.

We are fortunate to live in a country that has high quality medical care for premature and sick infants. Preterm babies tend to be much healthier than they were in years past due to advances in medical care. The rate of hospitalization for RSV illness has declined over the years in both those who did and did not get the palivizumab vaccine.

Research now shows not only that palivizumab prophylaxis has a limited effect on hospitalizations for RSV, but also no measurable effect on mortality and only a minimal effect on wheezing. Due to these new findings, the new recommendations limit the use of palivizumab compared to years past. I am sure there are infants that were born last season whose parents anticipated they would get the vaccine again this season, but with the new guidelines they will not be eligible. While this might cause anxiety among parents, it is based on good data that they wouldn't benefit from it. And remember that RSV is only one of the many viruses that cause significant illness in at risk babies, so the primary preventions of infection control are important regardless of whether or not an infant gets this vaccine.

New guidelines recommend the use of palivizumab in

• infants born before 29 weeks gestation and in the first year of life (previously 32 weeks)
• infants with significant congenital heart disease in the first year of life (previously 2 years)
• infants with a compromised immune system under 24 months of age (similar to previous recommendations)
• infants with chronic lung disease or who require at least 28 days of oxygen after birth and in the first year of life. If they continue to have need for oxygen, diuretics, or corticosteroids, they may qualify the second year of life.
• infants with neuromuscular diseases that affect the ability to clear the airway in the first year of life (previously 2 years)
• Alaskan Native and Native American populations may have expanded uses 

For those infants who qualify, they can receive up to 5 monthly doses during the RSV season. If they are born later in the season, they may require fewer doses. If a child has a hospitalization for RSV despite the vaccine, they stop future doses of palivizumab. 

It is still important for all infants, especially those born preterm, to use infection prevention strategies, such as 

• use breast milk whenever possible
• frequent hand washing
• clean toys regularly
• immunize household members against influenza, pertussis, measles, and other recommended vaccines
• limit contact with ill people 
• avoid smoke exposure
• avoid large crowds during the first winter season
• limit use of large daycare centers during the first winter season

Remember that even infants who are getting palivizumab vaccine prevention are still at risk for other illnesses, so it is important to use the above precautions in them as well. For treatments of cough and cold symptoms, please visit Cough and Colds.

Summertime = School Physical Time!

Summertime is the time many school aged kids get their annual check ups. In Kansas it is important that high school aged kids do their physicals after May 1st if they want to participate in a school sport. Other kids simply don't need to miss school on their birthday to do a physical. It's also good to avoid our office during sick season if possible. For all these reasons, summer time is a great time to have a well check. So if you haven't scheduled your physical exam yet, it's time to call! Appointments do fill in fast.

Why do healthy kids need to come in? It's recommended that kids have annual screenings for growth, development, injury prevention, and more. Actually there's so much that we are supposed to discuss and do at a well visit that it is impossible to do it all in a standard 20 minute exam. (See Drowning in a Sea of Advice for more.)

To help with this enormous volume of information, we use handouts and our website to share a lot so we can spend time at the visit discussing your other questions. Please take the time to register each of your children on our website so you will get a pre-visit e-mail. This is becoming even more important as we are trying to be your true medical home and provide the best care to every patient with their unique needs.

To register, simply go to www.pediatricpartnerskc.com and click on the "Create an Account" tab at the top of the page and fill in the information. (Note: Firefox seems to be the best browser for our website. If you are using Explorer or Safari and cannot get the site to load properly, try Firefox.)

Once you've registered the first child, it's easy to add family members. See our How To page for details!

By registering each child you will be able to not only receive these informational pre-visit e-mails, but also ask questions to our front office staff or your favorite providers in a confidential password-protected manner, and pay bills online. Everything is confidential and we will never sell your personal information. 

Our pre visit e-mails have age-specific information to consider before your visit. Please take the time to read through it. Each e-mail has a homework section that is especially important. If you do your homework before the visit, you will find the visit to run more smoothly and you will get more out of it.

This summer I am doing a test of sorts. We are including several printables on the pre-visit e-mail to make your office time easier. You can print your patient information sheet if needed (due once/year, usually at the annual checkup, so young children who come more often don't always need these). We are starting a pre-visit questionnaire that will help identify any concerns to address at the visit. I am hopeful that we will be able to cover more of your specific questions if we know you have read the information on the e-mail, so we don't have to repeat all of the standard things. This should allow much better use of time at your visit to address your concerns.

Watch for your pre-visit email and take the time to read it! I hope to see your kids for their well checks soon!

Sleep tricks

I preach about sleep to kids all the time, both at the office and at home. It is one of my three most important things for overall health along with eating nutritious foods and exercise. Most of us don't get enough sleep. Here are some tricks to get in a few extra minutes each day... they all add up!

photo source: Shutterstock

Most of these tips are appropriate not only for kids and teens, but also for their parents!

Know how much sleep is typical for every age group. A great infographic of this is found at the Sleep Foundation. Warning: It shows generalizations. For example: when tweens and teens go through a growth spurt many need 10-11 hours of sleep per night, which is more than the graph shows. Just remember that individuals are just that: individual.

Think of sleep as a currency. We can go into sleep debt when we don't get enough. If it's just a little loss of sleep, it is easy to catch up and pay back the debt. The further into debt you go, the harder it is to get out of debt. Don't let the bank come after you in terms of health problems!

• Listen to your body. If you're tired, you need more sleep. The longer you stay up, the harder it will be to fall asleep. It is ironic, but sleep deprivation leads to insomnia. If you suffer, try to get extra zzz's on a weekend to fill the deficit. But don't allow yourself to sleep so late that you can't go to bed on time that night. (Note: many kids get hyper when they're tired, so don't be fooled if they have lots of energy in the evening. If they don't wake easily in the morning, they are tired!)
• Routines. Go to bed and get up at the same times every night. If you stay up later on a weekend, be sure it isn't more than 2 hours past your ideal bedtime.
• If you have a hard time getting up, try to get natural sunlight as soon as possible in the morning. It helps set your circadian rhythm. If you can't get natural sunlight, turn on lights in your home.
• Conversely, start turning down lights a few hours before bedtime. Avoid screens (tv, computers, smart phones). Lights keep you from feeling tired. Don't let them keep you up!
• Journal before bed if thoughts keep you awake. People who spend bedtime thinking about everything can't sleep. Jot a few things down to give yourself permission to not think anymore. Sounds weird, but this "worry list" works for many people!
• Be active during the day. Lounging around makes you feel more tired during the day, but it is then harder to fall to sleep at night. Experts recommend avoiding exercise for a few hours before bedtime, but I know that is really hard for kids in sports. I don't have a great fix for that, unfortunately.
• Set the alarm for the last possible minute. Kids and their parents who hit snooze several times miss out on all that sleep that they are in a half awake zone. If you really don't need to get up until the 3rd snooze time, set the alarm for that time. You will be more well rested so it will be easier to get up immediately. Train your body (or your kids) to get up at that time. After several days of an extra few minutes of sleep, you'll notice the difference!
• Learn meditation or biofeedback. Some insurance plans might pay for this. There are apps available for smartphones and tablets, just do a search. Here's one review of apps to release tension. I have used the StressEraser, but it can be pricey. Searching Amazon or eBay will have less expensive options, allow you to browse several brands, and read customer reviews.
• Set the mood in the room: darken the room, get the temperature "just right", and find the number of blankets that helps you sleep. Setting up a fan or other white noise maker helps many people sleep. For more tips on setting up the perfect room for sleeping, see Bedroom.
• Keep kids out of the parent bed so everyone gets the best sleep. Snoring, different bedtime, and other body movements makes it hard to sleep together. No one sleeps well, which makes everyone grumpy the next day. 
• Reading at bedtime can be a great relaxing thing, but if you have a page turner, be careful to not get caught up in the book for hours. I find that stopping at a lull mid-chapter is better than waiting until the end of a chapter. A good author leaves you hanging at the end of a chapter and begging for more! Set a time limit and stop reading when time's up! That's what bookmarks are for.
• Avoid caffeine, especially hidden sources. I have occasionally gotten ice cream with coffee for a family bedtime treat, only to find out upon tasting it that it had coffee. Caffeine is often added to drinks, so read labels. But be careful! It might not say caffeine directly. Some are labeled as "guarana" -- a plant with caffeine. Pretty much anything that is labeled as an energy drink (or food) is a likely culprit.  Even decaf coffee has a small amount. Chocolate naturally has caffeine... the darker the chocolate the higher the caffeine content. Some pain relievers and other medicines have caffeine. Especially for those not accustomed to caffeine, it will disrupt sleep even if taken several hours before bedtime.
• Take a warm bath. This can help relax you for a good night's rest.
• Ask a family member to give you a massage or back rub. Again, a great way to relax!
• Warm milk or herbal teas might help some sleep.

Insurance Confusion. Please read and submit your comments!

I love my job. There are so many things to love, including helping kids get well and watching families grow together. Pediatricians get few instant gratifications, but many overall satisfactions of knowing we make a difference in the lives of children. (Warm heart!)

I knew there would be stresses to my job. All jobs have stress, and I expect things like

• time away from family working on weekends and holidays.
• sleep loss when there are urgencies or emergencies when I'm on call.
• sleep loss when there is a call about a non-urgency. (I do dislike those quite a bit, and yes, they do happen. Please respect our sleep and call during business hours for routine questions.)
• having to give bad news to a family of a very ill child.
• hearing stories of bad social situations and not being able to help immediately.

But one of the biggest stressors for me has nothing to do with the above. It has to do with billing and insurance. I keep thinking that if we educate our parents it will get better, but it doesn't. People who don't know their policy are upset about the charges left to them after the insurance company adjusts the bill and pays their portion.

Source: Shutterstock

During the summer we do a lot more physicals than other times of the year, so the end of the summer through the fall is when the phone call volume really picks up.

• If I knew there would be a charge for the autism screen I wouldn't have done it. Two autistic children recently diagnosed had a delayed diagnosis because parents refused the screen due to cost. Both families said they had no worries so didn't want the screening... so not screening isn't the answer.
• If I knew there would be a charge for the depression screen I wouldn't have let my teen take it. One of these complaints was a parent of a teen with a positive screen. The child was depressed and the parent hadn't suspected it. It is sad that even a positive screening is not worth the cost to a family due to financial circumstances, but every dollar is important for people paying bills. Yes, our health insurance system is broken!
• You should have told me there would be a charge for the ear infection treatment. They usually still want treatment for any sick symptoms. And I did warn them by email and the note posted in the exam room, but they usually say they were too busy to read it.
• I didn't know the lung function test wouldn't be covered by insurance. Neither did I. I don't have your insurance contract.
• I didn't know there would be a charge for ear wax removal. I couldn't see your toddler's eardrum. With that runny nose and poor sleep, it was important to remove the wax to see the eardrum.
• The list goes on...

I think the business of medicine stresses me more than the medicine because it is not what I'm trained to do. We have a business office that handles our billing and collections. I really don't want to get involved in that too much. It is a slippery slope. A big concern of mine is that I don't want to get involved in the billing because I don't want it to alter the way I practice in a negative way. Yes, I need to know the issues so our office can develop procedures to limit costs to families. I do believe that is important. But I don't want to follow medical practice guidelines on a subset of patients who can afford it and not do the recommended care for those who can't. If I do these services only for people who can pay for them (or those who know insurance covers the cost), I am not practicing good medicine for everyone. 

Guidelines are made by committees of well educated people who review all of the data and come up with the best ways to manage various issues. They recommend when we should do things, such as depression screenings, lead screenings, asthma follow up, get an X-ray, use a prescription medicine, and more. If I don't follow those guidelines simply because of cost, I am not providing great care. I only want to provide the best care. 

And if you bring up a concern at a well visit and I remind you that to discuss it might incur a charge to you, am I medically liable for not addressing it when you decide you no longer want to talk about it? It certainly won't get documented in the medical record, which means when you ask about it at a future visit I won't remember you mentioning it before. This can compromise good care because there isn't a good record of symptoms that could have been available if it was properly addressed at the visit. 

Our office really does try to help people with medical insurance issues.

On one hand, we try to limit costs to people. 

• If one drug is usually expensive, we try to order a cheaper option. (But we never know your formulary, they are all different and change often!)
• If I know a referral to a specialist probably won't result in any treatment that I can't offer, I will recommend against it. (If I think the specialist can offer more than me, then I am happy to refer so your child will get the best care. But don't call me when they charged more than you thought they should. Call them.)
• Our office offers extended hours so people don't have to go to the emergency department or urgent care (usually insurance charges you more for those services). 
• I try to talk parents out of vision screening in my office because if their insurance only pays for one per year I want it done by an eye specialist, not me! (See the 2nd scenario for more on this one.)

On the other hand, we try to anticipate and tell people in advance that insurance plans vary, and it is their responsibility to know their plan.

• We have a page dedicated to insurance on our website.
• Each of our well visit pages on our website reminds parents to check insurance.
• Before every well visit all patients registered on our web portal get an email with many important things regarding the upcoming well visit, including insurance issues.
• We have signs posted in each exam room reminding parents that separate issues discussed might incur a separate charge based on insurance.
• I post about insurance issues frequently on our Facebook page.
• I blog about this issue at times. Here. And here. And here. And here. And here. And of course this blog.

Yet the phone calls continue. Parents are upset about the way we charge them for things. This is misleading. Yes, the bill comes from us, but it we are only billing them what their insurance company tells us to.

Health care billing is complicated. We provide a service and apply the standard codes for each thing we do. Each code has a charge attached, based on typical payment for that code. We submit those codes to the insurance company. The insurance company adjusts the payment amounts to what our contract with them states they think are reasonable charges. Some companies allow more payment for one code, less for another. But it's not our choice how much they think is reasonable. We must write off the amount over their reasonable charge cost. The insurance company contracts with its clients to determine how much of each of those reasonable charge costs will be paid by them, and how much is the client's responsibility. We never see those contracts, so we don't know how much you will be billed at the time of service. We send the bill to the family based on what their insurance company tells us. We cannot adjust that amount -- to do so is insurance fraud. Simple as that. I'm not willing to commit fraud to decrease your bill, no matter how much I like you and understand your financial hardship.

Everyone in my office wants to provide good care, so we discuss guidelines and insurance issues in addition to other office policies and procedures on a routine basis. We review our practice for quality. We often hear complaints from staff that they want us to stop doing a recommended screening because they are tired of hearing complaints. But we continue to offer those that continue to be recommended because we care about the health of your child. We want to do what's right, not what's cheap. And I suspect that insurance will become more costly to people as the new plans roll out. Either you will pay a large premium to have more services covered, or you will pay less monthly but be expected to carry more of the load when you use services. 

Request: Please share how you think we can do it better. What are we missing? How can we better educate all of our families without spending the entire visit talking about possible charges instead of your child's health? We can't change the system (though that's the ultimate fix) but I want to know how we can make the system work better for all. 

It's [Sports, School, Camp, Yearly] Physical Time!

It's that time of year when school aged children and teens need physicals for school or camp entry or to participate in sports. Parents often want to work in a last minute "quick physical" for a form to be signed before a sport season starts or a child goes to a new school. Plan ahead so you can get an appointment at your preferred time!

Unfortunately some parents calling at the last minute are unable to get an appointment that fits their needs so they decide to go to a walk in clinic to just get the form signed. Keep reading to learn why this isn't a good substitute for a yearly physical in your child's medical home (AKA regular doctor's office).

Some parents don't think a yearly physical is important, and if not required to present a form to a school, sport, or camp, they simply don't do them. Their kids miss out on the benefits of a yearly physical.

Even when you think your child is healthy, there are several things that should be discussed, reviewed, and evaluated during the physical, so the visit isn't quick and it should be done in your child's medical home. If your child's regular physician is not available, there is still benefit to scheduling with another provider at your doctor's office as allowed by their policies. Past records are available to be able to compare current height to past growth. We can review vaccines and update as needed. We can update your child's record as needed since the last visit with new family medical history, changes in the home or school, and with your child's overall health.

Over the years I have "cleared" many student athletes by signing a pre-participation form required for high school sports or camps. On occasion I have not been able to sign the form, and this can lead to frustration for the athlete and his/her family.  If a physician or other licensed medical provider does not feel requriements have been met to "clear" an athlete for safe participation in sports, parents and their athlete often do not understand the "why" behind the need for further evaluation or treatment.

Common reasons to not clear an athlete for participation include recent concussion or a history of passing out that hasn't been fully evaluated.  I had one patient upset that I wouldn't sign the form because of a current broken bone... you can't play a sport in a cast! From the mother's perspective, she just wanted the form done today because the physical was today. From my perspective, the form can be signed when the child is able to play. I can't in good conscience say the student is able to play today if he is not. You don't want me as your child's pediatrician if I am able to attest to something I know is not true.

Please don't go to an urgent care or chiropractor to get the form signed when your regular doctor refuses due to a medical concern. I have seen parents do this -- omitting the fact that their child has passed out and needs further testing or had a concussion. That undermines the reason for the form in the first place! It is for your child's safety!

A glance at the Kansas Pre-Participation Physical Evaluation form's first page highlights many of the important topics to investigate. It would be impossible to completely cover every recommended topic at every physical, but standard recommendations include:

• Review of health history, including chronic conditions (such as asthma, diabetes, learning disabilities etc), hospitalizations, surgeries
• Review of family medical history
• Height, weight, Body Mass Index (BMI), vital signs (blood pressure, pulse, respiratory rate) - comparison to previous values is most helpful
• Puberty status
• Nutrition, exercise, and weight management issues - including performance-enhancing substances
• Sleep
• Risk factors (safety, smoke exposure, violence, alcohol use, screen time, internet safety, and more)
• Mental health (depression screening, drug/alcohol use, bullying)
• Physical exam (special attention to cardiac system, musculoskeletal, neurologic and other sport's preventing problems)
• Update vaccines as needed
• Laboratory evaluation as needed: cholesterol screening, anemia screening, and other risk-based testing

Not included in this list is following up chronic conditions, addressing the issues raised at the physical, refilling all medicines, etc. There are times that addressing one or two specific issues is appropriate, but often there isn't enough time to adequately address all concerns. A separate visit may be needed to be able to devote appropriate attention to each issue. Please don't save up a year's worth of concerns to discuss at one visit each year. 

A well visit is recommended every year for all children over the age of 3 years (more for younger children). If your child hasn't had a well visit in the past year, call today or request a physical through our portal! Don't wait until the last minute... summer physicals book quickly.

The yearly well visit can be used to address all sports and camp physical forms that need to be done. Please bring them to your visit with the appropriate sections pre-filled out to save time in the office.

Vaccine timing... is it too late?

It is common in the summer months for parents to worry about their child's vaccines being delayed by summer travel or simply scheduling conflicts.

The typical question I am asked is along the lines of, "He is due for his 4 month shots on July 5th, but we are on vacation. Is it okay to wait until the end of July?"

or

"Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?"

The answer to both questions: yes.

Vaccines are recommended with minimal intervals (you can't give them too soon) but if there is a delay for whatever reason (missed appointments, scheduling conflicts, immune compromise-such as cancer in a child or their caregiver) it is recommended to catch up as soon as possible.  Doses do not need to be repeated if the interval has been longer than recommended.

Conversely, it is not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in Kansas.  Some states have a leeway for giving doses early, but Kansas does not. This is an issue with some children moving to our state from a more lenient state. Maybe they get their MMR a couple days before their first birthday. Does this protect them against measles, mumps, and rubella? Probably. Does the school count it? No. They need to repeat it.

Another scenario is children traveling outside the US. It is recommended for international travelers over 6 months to get an MMR early due to worldwide outbreaks. This dose does not count toward the 2 doses typically given because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Another common scenario involves Hepatitis A and B vaccines due to the ages given and the intervals required.

The dosing interval for Hepatitis A is a minimum of 6 months. We typically give it at 12 months and 18 months, but if these appointments are scheduled with less than 6 months between, we typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine. This delay is okay. 

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.  If a newborn does not get the first Hepatitis B vaccine on the date of birth for whatever reason (too ill, parental preference, prematurity) and the one month well check is less than 28 days from the first dose, we delay the 2nd Hepatitis B vaccine until a future visit. This will push the 3rd dose back in most cases.

Each year the CDC updates the recommended vaccine schedule. We know it is confusing to parents, but we will help keep your kids on track!

Why Screen Free?

Every April and September there is a nationwide Screen-free Week to unplug from the screens and plug back in to our families.  Why do I support this wholeheartedly? Because I see the benefit from getting away from it all every once in awhile.  We live in a media-rich society, so I know that it is impossible to completely turn everything off... most of us couldn't do our jobs without a computer.  But I challenge you to substitute recreational screen time with other activites for just one week and see what happens. 

Some facts and statistics:

• Screen Time = television, video games, computer time, handheld games, social media, movies -- anything with a screen.
• The typical school aged child has 7.5 hours of screen time daily. That's more time than ANY other activity except sleep!
• The typical preschool child watches over 4.5 hours of screen time daily.
• Screen time is linked to aggression, ADHD, and obesity among other things.
• The American Academy of Pediatrics (AAP) recommends NO screen time under 2 years of age and no more than 10 hours per week for older children.
• The AAP recommends no televisions, computers, or other electronic media in children's bedrooms.
• An average preschool child sees nearly 25,000 commercials.
• Screen time inhibits sleep.   
• More from the links below!

Since my family has been doing this I find an interesting pattern: 

• my kids initially grumble (ok, it is a stronger disagreement, but...) 
• they quickly find other things to keep busy
• they play better together with less fighting
• they argue less with me when asked to do something
• we overall enjoy one another more
• at the end of the week they choose to do things without the tv or computers
• they slowly start to watch / do more on the screens
• they are once again addicted to the screen and I have to pull them away.

What can you do besides watch tv or play on the computer or game system?

• Go for a walk.
• Ride a bike.
• Play ball.
• Have a picnic.
• Play a board game.
• Read a book.
• Make up a play.  Be creative!
• Dance.
• Cook dinner together as a family.
• Talk to a friend or family member. Talk, not text!
• Go to the park or zoo.
• Check out the new aquarium.

It is an overall good experience. Read my post-Screen-Free Week Reflections from the last screen-free week here.

I will try not to be on line during the Screen Free Week, April 30-May 6th. (Hard work, I know... scanning the internet is my biggest pastime/hobby ~ AKA timewaster.)  

Join me off line and plug in to your families!  Have a fun week and I'll see you back on Facebook and Twitter May 7th!  

For more information:

Fact Sheets from Commercial Free Childhood

Common Sense Media 

Dr. Christakis on Media and Children

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

• height/weight measurements

• blood pressure screenings

• lab screenings (anemia, lead, cholesterol)

• vision and hearing screenings

• development assessments

• mental health screens

• more...    

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

• it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
• it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

Middle Man Payment Plan?

Healthcare billing is a very complex issue, mostly because people are familiar with purchasing things with money or credit in full disclosure of costs, not the complex system of insurance billing.  


People pay a lot for insurance, and then expect insurance to cover the cost of care, but they often do not realize the details of their contracts with insurance - AKA the Middle Man.  

Patient <--> Insurance <--> Doctor Office

This is  a long post, so bear with me... it is such an important but complex issue. I am only touching the surface here.  If you can't read the whole thing, at least hit the highlights at the bottom!

Typical purchase:  Buying a shirt. 

• I select my favorite store. 
• I look through the rack of shirts and pick one that is the right size and color.
• I look at the price tag and decide if I want it.
• Maybe I have a coupon or it's on sale - I can calculate the discount!  
• If it is the right cost and meets my needs, I make the purchase. I can choose cash, check, credit card.  Maybe I have a gift card! 
• If it isn't right for any reason, I keep shopping.

Healthcare purchase: Full of Unknown costs... making the decision to "purchase the product" much more difficult.  

Product? What product?

• "Product" is the expertise and knowledge of the healthcare professionals. 
• There is nothing to take home to show.  
• Time spent with the provider may or may not end up with a prescription or other identifiable thing that shows what the money was used for.  
• You might leave the office with as many (or more) questions because final diagnosis of a problem can be a process that takes time.
• You might disagree with the diagnosis or treatment given.  You don't have the option to choose another shirt. You already bought this one when you signed in.  You could buy another (2nd opinion) but you'd have to pay for both.  I hope you talk about these concerns at your visit... don't just worry that we "missed" something or did it wrong! 

Costs are becoming more important to the consumer as many insurance companies are putting more financial responsibility on their policy holders and covering less medical costs.  So it would be best if we let you know our fees and your payment amount before we see your child, right?  Well, there's a catch to that.  

The catch?  I don't know what your insurance contract requires of you, so it is impossible to accurately tell you what your real cost will be until after my office gets the insurance adjustment.  I don't know exactly what the insurance company will pay and what they'll discount ... my billing staff can make an educated guess based on past experience with a company, but it varies from case to case.

In this difficult economic time this places financial stress on families. I understand this and am happy to work with families on payment plans if they let me know their hardships, but often they simply yell that I billed it wrong. Because of contracts between my  office and the insurance company and the patient and the insurance company, there are many rules and laws regarding how to bill and collect payment.  


Back to Healthcare "purchase":

• Patient/consumer uses a service.
• Place of business (ie doctor's office) submits a bill based on well defined codes.  This bill doesn't go to the patient.  It goes to the Middle Man.
• Middle Man (insurance company) reviews the bill submitted.  
• Middle Man discounts each item to what they believe is a reasonable fee.  
• Middle Man pays the part of the adjusted fee that they are contracted to pay. 
• Middle Man sends us this information and we write off the discount they applied and bill the patient/consumer the difference.  
• We have provided a service and it is several weeks to months before any money is collected. Anyone in business knows the consequences of this timeline of money collection. 
• Payment collected from the doctor's office depends more on what the insurance company adjusts the bill to rather than the original bill itself. 
• Note: although the bill comes from us and is due to us, it is a result of your insurance plan/contract!  In general, the less expensive your plan for monthly health insurance, the more you are responsible to pay with each use.

Let's run through a couple scenarios of this Middle Man payment plan.


First scenario: Well visit plus additional concerns. A child is scheduled for a well visit but woke with a fever and cough.  He has an insurance company that requires a copay for each issue seen in the office.  We provide the care for a complete well visit (monitoring growth, development, nutrition, safety, reviewing vaccinations, etc) and bill for that service. We also ask further questions regarding this illness and symptoms and discuss management for the fever and cough.  Addressing and Documenting these issues (after all, the kid isn't well) is important.  When the bill is submitted to the Middle Man, the insurance company sees that the child is sick, so tells us to bill the family for a 2nd copay.  Our contract with this insurance company requires this, so we must bill to the family.  By law we must follow our legal contract.  To fail to do this is insurance fraud.  I'm not willing to go to jail to save a family a few bucks.  Sorry. I love my patients and want to help, but I don't want to have to go to jail for trying to do a good deed.


Second scenario: Screenings and tests sometimes, but not always covered. Another child is in the office for a 3 year old well visit and is due for a vision screening.  We know that most people either don't have vision coverage or their insurance only covers one vision test every 1-2 years.  The standard of care (ie what should be done if we want to provide the BEST care) is to do the vision test at this age.  This causes many possible scenarios, most of which equates to a headache for pediatricians:

• If a patient passes a vision screen done at our office and the insurance pays:  great. Rare, but great.
• If a patient's parent refuses the vision screen in our office (or fails to take the child to the specialist when we refer) because they feel the eyes are normal and don't want to pay, but later learn there was a problem that should have been addressed earlier for better outcome: parent is upset with us that we didn't insist on screening. The child also suffers from an undiagnosed vision problem.  
• If a patient passes a vision screen and insurance applies the charge to the deductible: the parent is upset at us for charging something "that wasn't needed. I knew the eyes were fine." (Note: we are the bad guy because the bill comes from us, despite the fact that it is their insurance company that chooses this payment method.)
• If a patient fails our vision screen and insurance pays us: parent is upset because we used up the once/year (or every other year) coverage, and now they pay out of pocket for the ophthalmologist.
• If patient fails our vision screen and insurance doesn't pay: parent is VERY upset because they must pay twice! (us and ophthalmologist) Why is this? Screenings by nature pick up some normals so they don't miss any abnormals. If a child fails at our office, they need to be seen by a specialist to confirm if there is or is not a problem.  Two visits by two providers with two fees.  Ugh!  

So... how many of these vision screening scenarios ended up with all happy?  ONLY ONE RARE CASE!

Please read your policies and ask questions to your insurance company before visiting the doctor so you know your financial responsibility.  Plan accordingly to save some money for healthcare needs.

One major issue we are seeing is described in scenario #1 above.  We follow the use of CPT codes as published by the American Medical Association. To bill both a sick and well visit on the same date of service, we add a Modifier -25 to identify separate preventive medicine service (well child exam) and a problem-oriented service (ear infection, hurt foot, earwax removal, etc) on the same date of service. This is the national standard, but not all insurance companies cover it the same.  Middle Man may tell us to charge the insured family a second co pay.  Why?  Because they want their members to pay their contracted portion of each visit.  Simply saving up multiple issues to be seen on the same visit day does not result in a person being less responsible for their portion of medical costs agreed to in a contract.  You are responsible for what your contract states.


Or maybe you simply have a high deductible plan.  You will be responsible for payments until you reach the magic number in your contract.  You have the benefit of lower monthly premiums, but expect to pay more each time you need medical care.


Another issue is labs.  Some insurance companies ONLY pay for labs done at their contracted lab. This means that quick Strep throat test we did gets charged to you.  Unfortunately we didn't know this from your insurance card.  Is it worth it to you for the convenience of knowing results right away to pay for the rapid strep, or would you prefer to wait for the lab to give culture results in a couple days? If this is important to you, call your insurance company.  Tell us before we do the test!


Billing codes separate out parts of services/product. Immunizations are a great example of this. There is the vaccine component, and there is an administration cost to cover costs associated with a vaccine:

• vaccine insurance -- they are expensive and need to be covered!
• temperature control of the refrigerator--did you know if the temp gets too high or low it alarms so our vaccine doesn't become ineffective? After hours one of us is automatically paged and we have to go in to see what is wrong?
• incidental supplies like syringes, needles, bandaids-- all the little costs add up!

Some insurance companies pay only the vaccine component, but not the administration fee. It goes toward the deductible.  Do you know how your plan works?

What does this all mean?

• We would like to provide the best care to our patients in a timely and economical manner, but we need your help identifying what you want done and not done due to costs before your visit. 

• If we address well and "not well" issues on the same day, it might mean a 2nd co pay or deductible for you to pay.  Some issues deserve a separate visit due to the nature of the concern.  

• We encourage you to do the recommended follow up labs and tests discussed at visits for the best medical care of your child.

• If your insurance company tells us to write off a portion of your bill, we do.  It is illegal to balance bill a patient.

• If your insurance company tells us to bill you for a service, we do.  It is illegal to write this portion off.   

• If you have a high deductible plan, save the money you save on premiums monthly in a special account for use when needed. 

• If you have any questions about your bill, please feel free to call our billing department to discuss. Please choose nice words with our staff. They are only the messenger!