High-Deductible Health Plans for US Children: Trends, Health Service Use, and Financial Barriers to Care.

OBJECTIVE: Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. METHODS: Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. RESULTS: The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). CONCLUSIONS: Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.

A Study of Pediatricians' Debt Repayment a Decade After Completing Residency.

PURPOSE: Pediatricians' education debt has been increasing. Less is known about the pace of their debt repayment. The authors examined patterns of debt repayment for pediatricians who completed residency from 2002-2004. METHOD: The authors analyzed weighted 2013 survey data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study. They categorized participants based on education debt level at residency completion ($0; $1-$49,999; $50,000-$99,999; $100,000-$149,999; ≥ $150,000) and explored debt repayment and well-being by starting debt group using multivariable logistic regression. RESULTS: Of 830 pediatricians surveyed, 266 (32%) had no starting debt and 166 (20%) had ≥ $150,000 in starting debt. A decade after residency, the percentage of participants who completely repaid their debt varied from 76% (68/89) of those with $1-$49,999 of starting debt to 15% (25/164) of those with ≥ $150,000 of starting debt. The percentage of participants concerned about their debt increased with starting debt level, with over half of those in the highest group concerned. Starting debt was associated with all examined measures of debt repayment and with recent financial difficulties among those in the two highest debt groups ($100,000-$149,999: adjusted odds ratio = 3.82, confidence interval = 1.17-12.43; ≥ $150,000: adjusted odds ratio = 4.55, confidence interval = 1.47-14.14). CONCLUSIONS: A decade after completing residency, pediatricians had made progress repaying their debt, yet many still expressed concern, especially those with the greatest amount of starting debt. As debt levels continue to increase, these issues could worsen.

Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians.

OBJECTIVES: To determine pediatricians' practices, attitudes, and barriers regarding screening for and treatment of pediatric dyslipidemias in 9- to 11-year-olds and 17- to 21-year-olds. STUDY DESIGN: American Academy of Pediatrics (AAP) 2013-2014 Periodic Survey of a national, randomly selected sample of 1627 practicing AAP physicians. Pediatricians' responses were described and modeled. RESULTS: Of 614 (38%) respondents who met eligibility criteria, less than half (46%) were moderately/very knowledgeable about the 2008 AAP cholesterol statement; fewer were well-informed about 2011 National Heart, Lung, and Blood Institute Guidelines or 2007 US Preventive Service Task Force review (both 26%). Despite published recommendations, universal screening was not routine: 68% reported they never/rarely/sometimes screened healthy 9- to 11-year-olds. In contrast, more providers usually/most/all of the time screened based on family cardiovascular history (61%) and obesity (82%). Screening 17- to 21-year-olds was more common in all categories (P?

Trends in Access to Health Care Services for US Children: 2000-2014.

BACKGROUND AND OBJECTIVE: Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children's access to health services and whether trends vary by race/ethnicity and income. METHODS: Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income. RESULTS: Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators. CONCLUSIONS: Children's access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.

Underserved Areas and Pediatric Resident Characteristics: Is There Reason for Optimism?

OBJECTIVE: To examine whether resident characteristics and experiences are related to practice in underserved areas. METHODS: Cross-sectional survey of a national random sample of pediatric residents (n = 1000) and additional sample of minority residents (n = 223) who were graduating in 2009 was conducted. Using weighted logistic regression, we examined relationships between resident characteristics (background, values, residency experiences, and practice goals) and reported 1) expectation to practice in underserved area and 2) postresidency position in underserved area. RESULTS: Response rate was 57%. Forty-one percent of the residents reported that they had an expectation of practicing in an underserved area. Of those who had already accepted postresidency positions, 38% reported positions in underserved areas. Service obligation in exchange for loans/scholarships and primary care/academic pediatrics practice goals were the strongest predictors of expectation of practicing in underserved areas (respectively, adjusted odds ratio 4.74, 95% confidence interval 1.87-12.01; adjusted odds ratio 3.48, 95% confidence interval 1.99-6.10). Other significant predictors include hospitalist practice goals, primary care practice goals, importance of racial/ethnic diversity of patient population in residency selection, early plan (before medical school) to care for underserved families, mother with a graduate or medical degree, and higher score on the Universalism value scale. Service obligation and primary care/academic pediatrics practice goal were also the strongest predictors for taking a postresidency job in underserved area. CONCLUSIONS: Trainee characteristics such as service obligations, values of humanism, and desire to serve underserved populations offer the hope that policies and public funding can be directed to support physicians with these characteristics to redress the maldistribution of physicians caring for children.

Early Career Experiences of Pediatricians Pursuing or Not Pursuing Fellowship Training.

BACKGROUND AND OBJECTIVES: Choosing career paths can be difficult decisions for residents contemplating fellowship training. This study compares the experiences of early career pediatricians who did and did not pursue fellowships. METHODS: We analyzed national, weighted data from pediatricians 8 to 10 years after residency (n = 842). Work environment, work-life balance, and satisfaction were compared for pediatricians who had pursued fellowship training (fellowship trained) and those who did not pursue fellowship training (generalist trained). Logistic and linear regression examined the independent effects of fellowship training while controlling for demographic differences. RESULTS: A total of 39% of the pediatricians (328/842) pursued fellowship training. The fellowship-trained group was less likely than the generalist-trained group to spend time in direct patient care and more likely to report learning opportunities in their work environment. This group was also more likely to report an income of ≥$150,000, although no difference was found when only full-time pediatricians were examined. Generalist-trained pediatricians were more likely to work <50 hours per week, have flexibility with their schedules, and be satisfied with time spent with their own children. Pediatricians in both the fellowship-trained and generalist-trained groups generally found their work to be rewarding and were satisfied with their lives. CONCLUSIONS: Although residents need to consider important life and career differences when contemplating fellowship training and general care, pediatricians in both groups can achieve overall life and career satisfaction.

Resident cross-cultural training, satisfaction, and preparedness.

OBJECTIVE: To describe the diversity of pediatric residents and examine relationships of cross-cultural training experiences with training satisfaction, perceived preparedness for providing culturally effective care, and attitudes surrounding care for underserved populations. METHODS: A cross-sectional survey was conducted of a national random sample of graduating pediatric residents and an additional sample of minority residents. Using weighted analysis, we used multivariate regression to test for differences in satisfaction, preparedness, and attitudes between residents with more and less cross-cultural experiences during residency, controlling for residents' characteristics and experiences before training. RESULTS: The survey response rate was 57%. Eleven percent were Hispanic, 61% white, 21% Asian, 9% African American, 9% other racial/ethnic groups; 34% grew up in a bi- or multilingual family. Ninety-three percent of residents were satisfied with their residency training, 81% with the instruction they received on health and health care disparities, and 54% on global health issues. Ninety-six percent of residents felt they were prepared to care for patients from diverse backgrounds, but fewer felt prepared to care for families with beliefs at odds with Western medicine (49%) and families who receive alternative or complementary care (37%). Residents with more cross-cultural experiences during residency reported being better prepared than those with less experience to care for families with limited English proficiency (adjusted odds ratio [aOR] 2.11; 95% confidence interval [CI] 1.40-3.17), new immigrants (aOR 1.91; 95% CI 1.32-2.75), and with religious beliefs that might affect clinical care (aOR 1.62; 95% CI 1.13-2.32). CONCLUSIONS: Pediatric residents begin their training with diverse cross-cultural backgrounds and experiences. Residency experiences in cross-cultural care contribute to feelings of preparedness to care for diverse US children.

Pediatric training and career intentions, 2003-2009.

OBJECTIVES: To examine trends in pediatric residents' training and job search experiences from 2003 through 2009. METHODS: Annual national random samples of 500 graduating pediatric residents from 2003 through 2005 and 1000 from 2006 through 2009 were surveyed. Responses were compared across years to identify trends. We examined resident demographics, training, satisfaction, career intentions, and job search experiences. Overall response rate was 61%. RESULTS: Between 2003 and 2009, there was an increase in the proportion of female graduating pediatric residents (69%-75%), residents from international medical schools (15%-23%), and levels of educational debt among the subgroup of residents with debt ($139 945 in 2003 to $166 972 in 2009). Residents consistently reported (>90% of residents) that they would choose pediatrics again if they had the choice. By 2009, the majority was very satisfied with the quality of their training in most areas, with ratings improving across years in caring for children with special health care needs, evidence-based medicine, and using information technology in practice. Although primary care remained the most common clinical practice goal, there was a modest decline in interest in primary care practice across survey years, whereas interest in subspecialty practice increased. Residents accepting both general pediatric practice and hospitalist positions reported less difficulty in their job search over time. CONCLUSIONS: Despite continually changing demographics of pediatric training programs, residents overall remain very satisfied with their decision to become pediatricians. Pediatricians continue to face difficult financial challenges associated with rising debt, but they also report increasing job search success.

Primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care.

OBJECTIVES: To compare satisfaction with specialty care by primary care pediatricians (PCPs), perceived barriers to care, and adequacy of specialist supply. STUDY DESIGN: A survey of U.S. pediatricians was conducted in 2007. PCPs were asked about satisfaction with specialty care for their patients, as well as supply of specific pediatric subspecialists. Responses of rural and nonrural PCPs were compared regarding 10 potential barriers to care. RESULTS: Most PCPs are satisfied with the quality of subspecialty care. However, they were not satisfied with wait times for appointments, and the availability of many pediatric medical subspecialties and several pediatric surgical specialties. Rural PCPs were significantly more likely to report these shortages compared with nonrural pediatricians; these included 9 of the 18 medical and 5 of the 7 surgical specialties. In addition to wait times for appointments, PCPs reported that subspecialists' nonparticipation in health insurance plans and lack of acceptance of uninsured patients were also barriers to obtaining subspecialty care for their patients. CONCLUSIONS: PCPs provide valuable insight into access to the pediatric subspecialty workforce. This survey of PCPs raises significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities.

Pediatricians and health literacy: descriptive results from a national survey.

OBJECTIVE: To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits. DESIGN/METHODS: A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900). RESULTS: Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics. CONCLUSIONS: Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

The effect of dual training in internal medicine and pediatrics on the career path and job search experience of pediatric graduates.

OBJECTIVE: To compare the job search experience and career plans of medicine-pediatrics (med-peds) and pediatric residents. STUDY DESIGN: Annual surveys of graduating med-peds and pediatric residents were compared from 2003 and 2004. RESULTS: The survey response rates were 58% for med-peds residents (n = 427) and 61% for pediatric residents (n = 611). Pediatric residents were more likely to be female or an International Medical Graduate. The groups were equally satisfied with their career choice and had equivalent debt. Med-peds residents were more likely to seek and accept generalist and hospitalist positions. Pediatric residents were more likely to seek subspecialty careers and research opportunities. More than 94% of med-peds residents expected to care for pediatric patients. Among residents seeking generalist positions, med-peds residents sent half as many applications to get the same number of interviews and offers as pediatric residents, were more likely to be offered their most desired position, and were more likely to accept a position in a rural area/small town. Med-peds residents had substantially greater starting salaries as hospitalists or generalists compared with pediatric residents. CONCLUSION: Med-peds and pediatric trainees differ in their career plans, although primary care is their most popular choice. Med-peds- trained physicians have an easier job search experience and greater market valuation.

Physician reimbursement levels and adherence to American Academy of Pediatrics well-visit and immunization recommendations.

BACKGROUND: There is concern that commercial health insurance reimbursement levels for immunizations and well-child visits may not be meeting the delivery and practice overhead costs within some areas of the country. There is also concern that insufficient physician reimbursement levels may negatively affect the quality of children's health care. OBJECTIVE: We examined the relationships between commercial health insurance reimbursement levels to physicians for pediatric services and rates of immunization and well visits for children and adolescents. DESIGN: Quality of care was measured by examining state-level immunization and well-visit rates for 2002, which were obtained from the National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS). Reimbursement data were obtained from the American Academy of Pediatrics Medical Cost Model. Variations in the child and adolescent HEDIS measures were examined as a function of physician reimbursement levels for pediatric services across states. HEDIS data were available for a total of 32 states. Partial correlations controlled for pediatrician concentration, as collected from the US Bureau of the Census and the American Medical Association Physician Masterfile data. RESULTS: Compliance with HEDIS immunization rates for all recommended vaccines was 60% for children and 24% for adolescents. By excluding the varicella vaccine, these rates increased to 70% for children and 44% for adolescents. Adherence rates for well visits were also higher for infants (60%) and children (59%) than for adolescents (34%). Physician reimbursement levels for pediatric services varied from 16.88 dollars per member per month to 32.06 dollars per member per month across states. Statistically significant positive correlations for reimbursement levels were found for 8 of the 16 HEDIS measures examined. Correlations with reimbursement levels were found for childhood immunizations (r = 0.42), infant well visits (r = 0.44), childhood well visits (r = 0.46), and adolescent well visits (r = 0.42). Reimbursement levels were especially strongly related to the rates of adolescent varicella vaccination (r = 0.53). When partial correlations were examined to control for pediatrician concentration, the correlations were reduced by 0.09 on average, suggesting that pediatrician supply may serve as an intermediary of the reimbursement relationship. CONCLUSIONS: Immunization and well-visit rates for infants, children, and adolescents were positively linked with physician reimbursement rates for those services. Although methodologic limitations suggest caution when interpreting these findings, more attention should be given to physician reimbursement levels as a possible predictor of immunization and well-visit rates as measures of quality of care and to the importance of reimbursement levels for pediatrician recruitment.

Pediatric training and job market trends: results from the American Academy of Pediatrics third-year resident survey, 1997-2002.

OBJECTIVES: To examine trends in pediatric residents' training and job search experiences from 1997-2002. METHODS: Annual national random samples of 500 graduating pediatric residents were surveyed, and responses were compared across survey years to identify trends. The overall response rate was 71%. RESULTS: From 1997-2002, there were more female residents and US underrepresented minorities and fewer international medical graduates. Each successive group of residents rated higher their preparation for fellowship training, for child advocacy, and for assessing community needs. These increases paralleled an increase in resident exposure to community sites as part of their residency education. Educational debt (in 2002 dollars) for residents increased substantially across survey years from an average of 64 070 dollars in 1997 to 87 539 dollars in 2002. Meanwhile, starting salaries (in 2002 dollars) for residents entering general pediatrics actually decreased. Interest in general pediatrics among residents decreased, whereas interest in subspecialty practice increased during this time period. Fewer residents with general pediatrics as a career goal had a job when surveyed, and fewer obtained their first-choice positions across years. CONCLUSIONS: Experiences of graduating residents over the past 6 years provide insights into changes in pediatric residency education and the pediatric workforce. Efforts by pediatric educators and academic leaders to increase community experiences and child advocacy and to encourage greater interest in pediatric subspecialty careers seem to be succeeding. Unfortunately, demand for general pediatricians is weakening, and residents are experiencing increasing debt burdens.

The practice of clinical genetics: a survey of practitioners.

PURPOSE: A survey of clinical geneticists was undertaken to learn more about current practice. METHODS: An attempt was made to survey all geneticists practicing in the United States to elicit information on a variety of issues. RESULTS: A total of 69% of geneticists responded. Most practice at a medical school, most receive a portion of their income from salary, and many receive personal financial support from research grants. CONCLUSION: The specialty of medical genetics is primarily housed in tertiary care settings. Although a substantial amount of time is required to see patients, reimbursement for these services does not cover the costs to maintain such practices.

Practice of pediatric otolaryngology: results of the future of pediatric education II project.

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.