Letter from the Idaho Chapter President November 2010

Letter from the Idaho Chapter President
November 2010
Collaborative Medical home Initiative
There are exciting initial collaborative discussions between Idaho pediatricians, family practitioners, and
general internal medicine with public and private payors on the patient centered medical home concept.
There have been a number of meetings initiated by Scott Dunn, President of the Idaho Family Physicians,
along with general internists and several representatives from the Idaho Chapter American Academy of
Pediatrics. This group has been given an executive clearance from the government to allow the different
parties to discuss possible payment options. The group is creating provider qualifications, guidelines for
the model of care coordination to improve health outcomes and achieve cost savings, and models of
payment to providers qualified as patient centered medical homes. The model of payment will most
likely be a fee for service and a per-member, per-month fee similar to Idaho Medicaid. The group is also
determining quality metrics for monitoring and reporting, and evidence-based health quality
improvements. I will report more on this as it unfolds.
Controversy at District VIII Meeting
The most controversial topic at the District VIII meeting in August in Austin, Texas was how the AAP
should respond to proposed legislature in 22 states (Arizona was the first) that allow random searches for
illegal aliens to be deported. There are reports from Arizona of law enforcement and vigilante groups
checking for illegal status outside ER’s, birthing centers, and medical clinics. This obviously has
important health consequences, as people forgo health care for fear of being deported.
The Arizona Chapter AAP has asked the AAP for direction, especially concerning the U.S. citizen
children of parents who are deported. This is even more of a concern when the child left behind has
special health care needs.
Tom Patterson, MD, Idaho Chapter AAP Vice President, is already using a handout for potentially illegal
families discussing important information to consider if one parent or both parents are deported.
Suggestions include documenting each child’s medical record/health concerns/medications, emergency
contact information, next of kin, and Power of Attorney to be given to friends/family if their children
remain in the United States. I will report more on this issue after the March Academy Leadership Forum
where this issue will be discussed by all state AAP chapters.
Synagis Season is Soon Upon Us…
Below is Dr. Tom Rand’s synopsis of the RSV Consensus Group:
The Synagis Consensus Group met on September 23, 2010. This group has met annually since
2006 and has been facilitated by the Idaho Chapter American Academy of Pediatrics (AAP). The
group includes general pediatricians and pediatric subspecialists who have come together because
they are vitally interested in prevention of RSV infection in high-risk infants and want to assure
that immunoprophylaxis against RSV is implemented effectively.
Seasonal RSV activity from Idaho for the past 11 years was reviewed. Strategies proposed by
CDC www.pediatrics.org/cgi/diu/10.1542/peds.2009-3221 for scheduling dosing in relationship
to historical data were applied to the season in Idaho. The Synagis Consensus Group encourages
all health insurance plans to have a coordinated starting date of December 1 for
immunoprophylaxis with Synagis. Moreover, eligibility should be based upon age of high-risk
infants on December 1. There is a small chance (fewer than one in ten seasons) for onset of RSV
season prior to December 1, and in that event, a recommendation for earlier dosing will be
Lung development of mildly pre-term 32-36 week gestation infants was reviewed. A
considerable body of literature indicates that outcomes of RSV bronchiolitis (hospitalization,
ventilator or ICU care, mortality, and morbidity) are similar between 28-31 and 32-36 week
infants. These research publications call into question recommendations which limit use of
immunoprophylaxis against RSV with Synagis in the mild pre-term population.
The Synagis Consensus Group continues to have grave reservations regarding the changes in
AAP COID Red Book criteria between 2006 and 2009. In particular, administration of one of
three doses of Synagis in the fall may leave 32-34 week gestation infants unprotected when RSV
activity is potentially greatest in February through April. Moreover, the evidence-base does not
establish that 32-34 week gestation infants are at substantially lower risk of hospitalization or
morbidity from RSV bronchiolitis. The Synagis Consensus Group favors guidelines by the
National Perinatal Association www.nationalperinatal.org
Nevertheless, the Synagis Consensus Group recognizes that 209 COID Red Book criteria are a
national standard now followed by the majority of health insurance plans to preauthorize
coverage for Synagis. Some medical risk factors in infants less than 24 months old are not
explicitly addressed in the criteria, and some latitude in preauthorization of Synagis is important
when the ordering physician submits requests for preauthorization and specifies additional
medical risk factors.
The group also discussed use of Synagis while high-risk infants remain hospitalized in the NICU.
Dosing as close to NICU discharge as practical is important to minimize potential interruptions in
Synagis dosing as outpatients while RSV season is underway.
Physicians participating in the Synagis Consensus group are available to assist clinics or health
insurance plans with interpreting recommendations for high-risk infants.
Participants included Perry Brown, MD, Shannon Jenkins, MD, Joseph Kiehl, MD, Jennifer
Merchant, MD, Thomas Rand, MD, Katherine Stevens, MD, Benjamin Tippets, MD, Aaron
Weiss, MD, Noreen Womack, and Paul Ziefa.
Synagis pricing (for those that give this through their clinic) went up over 10%. Pricing for a 50 mg vial
is $1076 and a 100 mg vial is $2032. Medicaid reimburses $978 per 50 mg vial plus 10% for overhead
which allows us to just break even. In our clinic we buy the 100 mg vial and split it on “Synagis Days.”
If you have any comments or questions, please contact me at hardcrei@cableone.net or Sherry Iverson at
Creighton A. Hardin, MD
President, Idaho Chapter American Academy of Pediatrics