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President's Perspective
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By Jennifer Mellick, MD, FAAP
As a pediatrician, I can't count the number of times I have quoted the African proverb about raising children - "It takes a village to raise a child." It is not only something I have told new parents, but truly believe and live. I am certain that I first heard this, meaning truly listened to it and took it to heart, as a new mother in medical school when I came to the realization that I couldn't be everything for my daughter. What I continue to learn as a mother, pediatrician, and now member of the Kansas AAP is how big this village really is. How big this village must be for each child to be able to fully realize their potential and find their own contribution to life in a community.
Nothing I have ever accomplished has happened in a vacuum. My successes are attributable to so many of my partners over the years. I have been so lucky in the wonderful partners I have found along the way. My husband, parents, teachers and friends have been excellent partners in my private life. My partner physicians, attendings, and fellow members of organizations have helped me to remain focused and forward moving in my professional life. Helen Keller said, "Alone we can do so little; together we can do so much. " This will be so important for each Kansas pediatrician to remember as we move through the years. Challenges will come, there is no doubt, but with the right partner - we can be a positive part of the village for Kansas kids.
The Kansas Chapter of AAP has been fortunate over the years to have many successful partnerships. I am grateful for my fellow KAAP members who represent the KAAP and our membership within many of these groups. Several deserve special mention. The Kansas Maternal Child Health Council (KMCHC) works to advise the Secretary of Health and Environment on ways to improve the health of families in Kansas. Our membership is represented by three tireless pediatricians, Dr. Dennis Cooley, Dr. Susan Pence, and Dr. Kari Harris. The Immunize Kansas Coalition (IKC) is a statewide organization that works on immunization issues for both children and adults. Our representative from the KAAP is Dr. Gretchen Homan. Several of our members, especially Dr. Steve Lauer, from the University of Kansas, Department of Pediatrics have partnered on Smoke Free for Kansas Kids. I am beyond amazed at how hard pediatricians are willing to work for their patients even if they aren't directly their patients.
The Kansas Chapter continues to seek out new relationships to help promote health for the children of Kansas. Within the last year we have developed a wonderful new program to help support Breastfeeding Friendly Practice Designations to recognize the work pediatricians have been doing for years to support breastfeeding. This program has developed a deeper relationship with the Kansas Breastfeeding Coalition. I know with certainty, that these partnerships I have mentioned only scratch the surface of the work being done in Kansas to promote health for children. If any of our members are involved in a great partnership, let us know. If we at the KAAP can help, we would love to be involved. We need to continue to work together to further our goals. We need to support each other in our endeavors to promote health, prevent disease, and help our children realize their future. "The only limit to our realization of tomorrow will be our doubts of today." - Franklin D. Roosevelt
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| Issues & Commentary |
CMS Denies KanCare One Year Extension
By Dennis Cooley, MD, FAAP, KAAP Legislative Coordinator
In another example of the dysfunction of KanCare, the state's privatized Medicaid program, CMS sent a letter dated January 17 of this year denying the program's request for a one year extension. The letter stated KanCare was "substantially out of compliance" with federal regulations. It sited poor coordination by KDHE and Kansas Department of Aging and Disability Services in not holding the three private MCOs accountable. CMS stated they had "received a significant number of complaints and concerns from beneficiaries, providers and advocates regarding the operation of the KanCare demonstration that were substantiated during a CMS onsite review in October 2016."
According to an article in the Kansas City Star, state legislators were caught off-guard by the letter. One important legislator told the Star he felt "blindsided" by the announcement. After all in the State of the State address just a few weeks earlier, the Governor lauded KanCare and called it "innovative".
Still it is beyond me how anyone familiar with the program could have been surprised. Almost from its inception in 2012 there have been problems.
- The MCOs have essentially done what they pleased with administrative burdens for providers and we have had to suffer.
- For the last three years, the state has left vacant the position of Inspector General who would have oversight over the program.
- Complaints have been frequent.
- There was the issue of the enrollment backlog and in truth I am not sure it has ever really been resolved.
- Just last fall a consultant submitted a report to the oversight committee that described significant problems with the program.
And to top it off payments to providers were cut 4% to help balance the budget. So my only surprise is that it has taken so long.
The Brownback Administration officials have decried the CMS stance as political. They have said they are already addressing many of the issues. But how often have we heard this only to find out nothing has changed. While I won't deny that there is some politics involved, I feel that the action by CMS can mostly be attributed to them finally saying enough! That is something many of us have been saying for some time now.
With over 30% of the state's children in KanCare something needs to be done to fix this program. I can only hope with a change in the legislature this year that something gets done. For the sake of Kansas' children, it can't happen too soon.
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| ABP Update |
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By Ramona DuBose, American Board of Pediatrics
The ABP Pilots MOCA-Peds to Replace Secure Exams
In January 2017, the American Board of Pediatrics (ABP) launched a pilot program that could revolutionize the way pediatricians are assessed throughout their career.
The new program, called Maintenance of Certification Assessment for Pediatrics (MOCA-Peds) allows pediatricians to answer multiple-choice questions at their convenience via computer or mobile devices.
Each quarter of the year, 20 questions will be made available in each certified pediatrician's portfolio (the secure section of
www.abp.org
). Once a question is opened, the pediatrician has five minutes to submit their answer. During that time, they may use reference materials, but may not collaborate with a colleague. All 20 questions must be answered by the end of each quarter, before the next round of questions is posted. Pediatricians will receive immediate feedback as soon as they submit their answer to a question. In addition to knowing whether their answer was correct, they will receive a brief explanation and references. The goal is to foster enhanced learning.
The 2017 pilot was open to all those who had a general pediatrics (GP) certification exam due in 2017. Of the 6,800 pediatricians eligible for MOCA-Peds this year, 75 percent (5,200) signed up. As long as they remain meaningfully engaged in MOCA-Peds, they will not have to take their exam in a secure testing center.
Pediatricians with GP exams due in 2018 will be eligible for the second year of the pilot. A decision will be made during the pilot about whether to make MOCA-Peds the assessment tool for all pediatricians. Right now, MOCA-Peds is available only for general pediatrics, but if the pilot is successful, it will be expanded to subspecialties.
Pediatric Hospital Medicine Certification Approved
In October, the American Board of Medical Specialties agreed to recognize Pediatric Hospital Medicine (PHM) as a subspecialty. The ABP will sponsor the PHM certificate and will be responsible for the training and assessment criteria, and for awarding the certificate to diplomates who meet criteria and mass the initial certifying exams.
The ABP is finalizing eligibility requirements, including an initial practice-based pathway for PHM certification as ACGME-accreditation is developed and awarded to training programs.
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| Pediatrics in Review Eligible for MOC-2 Credit |
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Dr. Karen Remley, AAP CEO/Executive Vice President, announced that the ACBOPUB has approved Pediatrics in Review will be eligible for MOC part 2 credit. The AAP is working hard to meet member's educational and maintenance of certification needs! Below is the official announcement.
From the May 18, 2016 minutes of the Advisory Committee to the Board on Publishing (ACBOPUB):
"Pediatrics in Review (PIR) is approved for Maintenance of Certification (MOC) part 2, starting in January 2017, offering 20 MOC points."
From the January 2017 Division of Journal Publishing ACBOPUB Management Report:
"The journal is approved to offer 30 Part 2 Maintenance of Certification (MOC) points beginning in 2017. Included in each monthly issue of the journal will be three quizzes eligible for MOC points. Subscribers must complete the first 10 issues or a total of 30 quizzes of journal CME credits and achieve a 60% passing score to claim MOC credits as early as October 2017."
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| Allergy & Asthma Update |
 By Kirsten E. Evans, MD, FAAP
There are several newsworthy items in the world of asthma and allergy in the last few months. The major one is the revision of recommendations regarding the introduction of possibly allergenic foods, namely peanuts. Following the LEAP study, the AAP, in conjunction with the AAAAI, has released new guidelines hoping to reduce the incidence of peanut allergy.
The guidelines are based on level of risk of allergy in the infant. The first recommends that,
AFTER allergy testing, infants at greatest risk for peanut allergy, that is, those with severe
eczema and/or egg allergy, be introduced to peanut at four to six months of age. The peanut
containing product should be offered after other foods, not as the infant's first food. If the infant
is allergic, introduction of peanut should be done under a physician's supervision. These infants
should receive six to seven grams of peanut protein three times a week, as in the LEAP study, for
five years, to ensure allergy avoidance. The second guideline is for babies with mild to moderate
eczema, who should receive peanuts "around six months of age" as the family prefers, with or
without an evaluation for allergy. The third guideline simply says that infants without eczema
can have peanuts whenever the family wants. The main thrust of these changed guidelines is the
recognition that withholding allergenic foods until two or three years of age, as was
recommended in the past, does not prevent allergies and may in fact worsen the risk of
developing them. The experts again caution, however, against using peanuts as a first food especially in at risk infants, as there have already been several cases of anaphylaxis reported.
The second item worthy of note is that CVS has contracted with Adrenaclick to provide a generic version of this epinephrine for a fraction of the brand name price. CVS is currently charging $195.00 for a twin pack, providing a savings of some $300-400 to patients' families. Physicians can write either for generic epinephrine auto-injector or write for Adrenaclick with "generic substitution permitted." These are for patients only and will not be provided to physicians' offices or to schools unless a patient's name is provided.
Finally, the FDA has approved the use of Symbicort (budesonide-formoterol fumarate dehydrate) down to the age of six. The medicine has been in use for years for twelve and up, but now has shown safety and efficacy for children six and up, thus adding another option for managing moderate persistent asthma.
That's it from Asthma and Allergy! If anyone has questions, concerns, or issues that I can help address, please let me know:
kirsten.e.evans@gmail.com.
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Pediatric Payment Corner
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By Jonathan Jantz, MD, FAAP
What is HEDIS and why does it matter? The acronym stands for
Healthcare Effectiveness Data and Information Set and consists of 81 measures across 5 domains of care.
HEDIS is a tool that evolved in the late 1980s from a need to evaluate quality of health care delivery by various systems that includes providers, hospitals and insurance companies. It is currently used by more than 90% of health plans in the United States including Medicare and Medicaid. Since the measures are specifically defined, HEDIS data creates a level playing field for comparing the performance of various health plans directly. Health plans review the results to see where they excel and where they need to improve. At that point, if the area in question is clinical, they put pressure on the providers in their network to improve various measures.
HEDIS measures include a wide range of important health issues that most of us agree are important. Some of the ones pertinent to pediatricians include:
- Asthma medication use. (This might be whether your patients are refilling their preventative medications appropriately or whether they are over using rescue medications.)
- Controlling high blood pressure.
- Antidepressant medication management.
- Childhood and adolescent immunization status.
- Lead screening in children.
- Well child visits in the first 15 months of life.
- Well child visits in the third, fourth, fifth and sixth years of life.
- Children and adolescents' access to primary care defined as the percentage of members from 12 months to 19 years who have had a visit with their PCP, usually defined as a well visit.
- Follow up care for patients prescribed ADHD medication.
The primary stated goal is to use the data to make improvements in their quality of care and service. Purchasers of health care frequently use the data to help them select the best health plan for their needs. NCQA (National Committee for Quality Assurance) is the body responsible for monitoring and auditing the data for quality and to oversee the program since the early 1990s. The results are then published in various "report cards" that may appear in magazines and even local newspapers.
The current issues focused on by HEDIS varies from year to year depending on feedback from employers, consumers, health plans and public debates. Also included is the CAHPS 5.0 survey Consumer Assessment of Provider Healthcare and Systems) which measures member satisfaction in multiple areas including claims processing, customer service and getting needed care quickly.
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| Recent Outbreak of Vaccine-Preventable Diseases |
by Susan Pence, MD, FAAP
I remember in medical school when my professors taught that we would "never see X disease" due to vaccination. I hate to say it, but I think we can all agree that they were wrong. In recent years, several waves of the anti-vaccine movement have found traction throughout the United States and in several of our communities in Kansas. Some of these groups are due to poor education and/or understanding of vaccines or the diseases that we vaccinate against. Others are feeding off of chiropractors who are very widely known as anti-vaccine. Still others are due to conspiracy theorists. Regardless of the reason many of us see anti-vaccine or vaccine-hesitant families. The lack of vaccines are rapidly decreasing our herd immunity.
Recent out breaks of mumps, measles, and pertussis are beginning to pop up in many communities throughout the US. Unfortunately this is rapidly increasing the risk of each of us coming face-to-face with a possible case of once almost eradicated diseases. Chicken pox is common, but would you recognize possible mumps? Two large-scale outbreaks have been occurring in our back door. Mizzou and northwest Arkansas are both facing large scale and prolonged outbreaks. These have each led to small scale outbreaks in Kansas. One occurred at the University of Kansas in Lawrence after the winter break. The second has occurred in my small rural town of Pittsburg.
Our local outbreak came suddenly, spread rapidly, and exposed a large portion of our community. The indexed cases were all within one family; however, unvaccinated infants were exposed prior to the medical community figuring out that mumps could be a cause. It has now spread outside of that initial family grouping.
I write this to remind all of us that we need to continue to review our communicable diseases that we typically vaccinate against. Think of the mumps with jaw swelling. Think of pertussis with the coughing child with post-tussive vomiting. Mumps is one of the state reportable diseases that should trigger a call to KDHE within 4 hours of suspected mumps. The epidemiologists there can approve PCR testing through the state. You can also call your "local" neighborhood pediatric infectious disease specialist.
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Finding and Decreasing Hidden Sugar in
Children's Diets |
By Carissa Garey-Stanton, MD, FAAP
As many pediatric healthcare providers have noticed, America has a growing problem with pediatric obesity and chronic disease. Childhood obesity has tripled from 5% to 18% in the last 30 years, and currently 1/3 of children are overweight or obese. Along with the obesity comes type II diabetes, which has increased in children 30% from 2001 to 2009. Other chronic diseases are occurring more in children. For instance, asthma has doubled since 1980. One of the reasons I chose pediatrics was to treat less chronic disease, but increasingly pediatric healthcare providers are having to treat type II diabetes, hypertension, dyslipidemia, and other chronic ailments. Per an article by JM Perrin in JAMA, the rate of rise of chronic disease in children is too quick to be genetic shift; therefore it is mostly attributable to environmental causes. One of the major contributing factors is a shift to a diet that is less in whole natural foods, and more in highly processed foods that have high calories (energy dense) but nutrient poor. Approximately 30-40% of daily energy in children's diet is consumed as highly processed foods that have sugar and other additives added to them but nutrients taken out. This creates a diet that is not only high in calories causing overweight and obesity, but also low in essential nutrients like vitamin D, calcium, fiber and magnesium which may contribute to chronic disease.
So what can we do? Well, as a society we need to shift back to 1970 (when childhood obesity was at a baseline 5%) to a diet that was balanced with whole natural foods eaten mostly at home. America needs to modify environments (home, school, workplace, grocery stores, restaurants) to make it easier to choose healthier whole foods instead of highly processed convenience foods. What we as healthcare providers can do is educate and help families choose a diet that is higher in whole natural foods and less highly processed foods, something I term "eat closer to nature".
Nutrition and obesity research is showing that one of the most high yield areas of focus to help families get healthier is decreasing added sugar. As a dietitian and a pediatrician, this is something I've stressed to my patients and families, but for numerous reasons it has not hit mainstream knowledge until the problem of obesity has worsened and more literature has developed. Now knowledge about the dangers of hidden sugars is coming out of hiding. The American Heart Association (AHA) recently released a scientific statement about added sugars and cardiovascular disease risk in children. The article reviews the current literature on the cardiovascular health effects of added sugars on children. It found the consensus of research shows excess added sugar in children's diet leads to increased adiposity, elevated blood pressure, and has adverse effects on dyslipidemia. They also found that added sugar introduced before the age of 2 predicted future sugar consumption and taste preferences.
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| It is Time to Register for the Spring CME Meeting! |
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Join us for Progress in Pediatrics (PIP) - Spring 2017 on April 20th and 21st at the Overland Park Marriott. The Thursday evening dinner on April 20th features Pamela Gonzalez, MD, MS, FAAP speaking about adolescent opioid use disorder. Dr. Gonzalez is a member of the AAP Committee on Substance Use and Prevention, Core Project Team member of AAP Practice Improvement to Address Adolescent Substance Use, and Steering Committee Member to Providers' Clinical Support Services for Opioid Therapies and Medication-Assisted Treatment.
Plenary on Friday, April 21st includes expert speakers and important topics like medical marijuana, electronic cigarettes, concussions, and much more.
Read the full agenda, meet the faculty, register online and book your hotel room here.
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| KPF Update |
Thank you to the generous supporters who contributed to the Kansas Pediatric Foundation's Year End Appeal. We were able to meet our full matching gift provided by the Overland Park Regional Medical Center Pediatric Services and add over $65,000 to the Turn a Page. Touch a Mind.® (TAP-TAM) Literacy Endowment.
Turn a Page. Touch a Mind.
® (TAP-TAM) put over 125,000 books in to the hands of Kansas kids in 2016, and that number will continue to grow this year. This year we will continue work to strengthen the endowment so we can continue to support all 83 sites far into the future.
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| Kansas Breastfeeding Friendly Practice Designation |
The Kansas Chapter, American Academy of Pediatrics (KAAP) has been busy working with physician practices throughout the state and awarding Kansas Breastfeeding Friendly Practice Designations. Participating practices receive a one-hour on-site training with free CME credit, tool kit, and promotion as a Kansas Breastfeeding Friendly practice.
Congratulations to the following practices what have taken advantage of the free CME education and have earned their designation:
5 Stars
Children's Mercy West Clinic - Kansas City
University of KS Dept. of Family Medicine - Kansas City
4 Stars
Ashley Clinic - Chanute
Pediatric Partners, PA - Overland Park
Heartland Primary Care - Lenexa
Drs. Morris and Hill Medical Practice - Fredonia
For information on how your practice can become breastfeeding friendly, contact Mel Hudelson at (913) 530-6265 or
mel.hudelson@kansasaap.org.
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| Breastfeeding Seminar |
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Don't miss Dr. Alison Stuebe's dynamic program on March 9, 2017 at Wesley Medical Center focusing on clinical management practices in the treatment of breastfeeding-associated pain. Participants will leave with an effective differential diagnoses tool for making clinical treatment decisions to treat breastfeeding pain.
Alison Stuebe, MD, MSc, FACOG, FABM is an Associate Professor in the Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology University of North Carolina (UNC) School of Medicine.
Learn more about the seminar here.
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| National Dairy Council's Fuel Up to Play 60 |
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Did you know that 1 of every 5 children live in households without consistent access to food? Children who live in food insecure households are more likely to become sick, recover from illness more slowly and hospitalized more frequently. Food insecurity can also affect a child's ability to concentrate and perform well in school. Hunger is also linked to high levels of behavioral and emotional problems.
As a pediatrician, you play a central role in screening and identifying children who are at risk for food insecurity and connecting them with community resources. Local food banks and USDA programs such as the National School Lunch and School Breakfast programs, Summer Food Service program and the Supplemental Nutrition Assistance Program (SNAP) all help to reduce hunger in children.
Midwest Dairy Council has partnered with the Kansas City Chiefs to create a handout for pediatricians to share with families who may need food assistance. You may customize the handout to list feeding programs and agencies in your community. Here is a template available to customize.
Fuel Up to Play 60 is an in-school nutrition and physical activity program launched by dairy farmers, and NFL, in collaboration with the UDSA, to help encourage today's youth to lead healthier lives. Here in Kansas you can find Fuel Up to Play 60 in over 1,200 schools reaching nearly 447,000 students.
To learn more about Fuel Up to Play 60, visit www.FuelUptoPlay60.com or to speak with a Midwest Dairy Council Dietitian, call 1-800-406-MILK.
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