Thursday, May 26, 2016

Adolescent Health Care -- Analysis and Direction

Adolescents are among my favorite patients.  I remember with some pain my own adolescence each time I see a teenager in the office, and I try all the harder to help the patient before me.  Most of them are just so endearing.

It pains me to think how underserved our American teenagers are by medicine!  It should be much better.  So, here is a little paper I put together.  Maybe it will be a help.  Who knows?  Stranger things have happened.  I guess.  (in 1,680 words.)


Serving adolescents properly with health care has always been difficult. Utilization of adolescent health care services (AHCS) is far below where it should be, to the detriment not only of patients, but to the nation's health as a whole. When we know that illnesses often begin in adolescence, and that they could be avoided – or at least detected early and treated at that time – why are they so underutilized?

An article last year in Pediatrics by Hargreaves et al. cites a survey of adolescents and parents. What were the impediments to seeking health care for the teenagers? The results were interesting. (The article is at:

  • 37.2% - unmet need perceived to be of low importance
  • 32.0% - non-financial access problems
  • 22.7% - negative consequences of health care
  • 14.8% - cost

Now, that's pretty amazing. It would seem that beliefs and inconvenience were the major reasons these kids didn't get the care that experts believe they needed. A mere 15% said that the money it would cost to get these services was an impediment.

This is an inconvenient conclusion. We love to solve problems by throwing money at them, but these results would seem to suggest that money isn't the issue. Does that mean we will actually have to think this thing through? What a bother that would be!

My thought is that, yes, we'll have to think it through, but not to worry, at the end we can throw some money at the problem with some hope of success, although not immediate. These things do take time. So here's the way I put it together.

First, I bet that the newness of adolescent medicine (AM) as a concept is part of the difficulty. Instead of simply a way station between childhood and adulthood that must be endured, we now see adolescence as a separate stage of life, with its own epidemiology that features major components such as injuries, suicide, drug and alcohol problems, mental and behavioral disorders, and sexual/reproductive issues. It is only in recent years have we have recognized that primary prevention, early detection, and interventions in these issues can not only be effective in helping the kids in the present time, but can also pay dividends in better health for decades to come. It is also only in recent decades that adolescent medicine (AM) has been seen as a distinct entity to be served by pediatricians, with its own subspecialty professionals as sources of instruction and as providers of care to difficult cases. In other words, it's new. Indeed, when I was in training in pediatrics at UCSF, we were not allowed to see patients after their 13th birthday! That's how new it is.

I also bet that this newness hasn't filtered down to the general populace fully. The families and the patients are not aware that there are issues in adolescence that should be approached medically. Adolescents typically feel invulnerable as their prefrontal cortexes are still myelinating, so they don't want to come in, and families just don't realize the potential value of ACHS. In addition, I'm sure the difficulties of confidentiality and embarrassment dissuade adolescents from accessing the services.

Also, note the 32% of the survey who said there were non-financial access problems. Lots of patients don't think of the pediatrician as someone to turn to for adolescent problems – although this is changing – and many pediatricians don't really like to deal with adolescent problems that much, and there are many places where full fledged pediatric services aren't available.

OK, so that's “beliefs” and “access,” rather than a direct financial barrier, which only 15% cite as the problem. Still, it seems to me as a health care policy analyst who tends often to think in economic terms, that money can still be an important part of the problem. And as a usually liberal Democrat, I think I can see my way clear to throw money at the problem. But if we are going to do that, we will have to diminish the salience of that 15% number.

First of all, I'm not sure that 15% is the right number for people who are deterred by cost. People do a lot of rationalization when they give reasons for acting as they did. It is very difficult for many people to think, “I didn't give my kid enough care because I wanted to save money.” It's more comfortable to think, “I didn't go to the doctor because I didn't think it would help,” or, “I didn't think doctors took care of that,” or, “I figured he would grow out of it.” Those ex post facto explanations still allow a parent to think that he or she was acting as a good parent. So I'm pretty sure that the 15% number is factitiously low.

Second, even though the ACA was supposed to make care “affordable,” we all know that there are still significant financial barriers to care. Well child visits are now free, but many teens and young adults still lack coverage, and for those who have it, high deductibles and high coinsurance are still problems, many policies are not covered by the ACA and have even higher barriers, and coverage of just those conditions often experienced by teens – mental health, behavioral, and sexual/reproductive services – are often under-covered or uncovered.

So, I would contend that direct financial barriers are still a problem, much in excess of the 15% reported who are affected by it.

Indirect effects of insufficient financing are also important. Clinicians are paid poorly for ACHS. It is well known that procedural specialties are more generously paid than the so-called cognitive specialties, which would include providers of ACHS. But even within the cognitive specialists, ACHS services are particularly undervalued. For instance, there are special billing codes for preventive care services – that is, well child visits. It is so, so much harder to see a 14 year old than a 7 year old. Yet the clinician is paid only a few dollars more to see the 14 year old, which is ridiculous. It is just hard to get paid for visits where the clinician does a pelvic exam, or where the clinician delves into a teen's depression, which over 10% of teens have. For payment, then, a case could be made for AHCS being the lowest of the low.

What does this low payment pattern lead to? For one thing, it leads to general pediatricians providing fewer AHCS than they otherwise would. That's just straight economics. If you are paid poorly for a service, you will tend not to encourage patients to patronize you for that service.

Second, well-financed services can use their money to construct attractive and even luxurious physical settings, to employ a host of aides, and to advertise to the public. I challenge anyone to think of AHCS settings and advertising to rival that of cardiac surgery.

Third, practitioners of financially favored fields hold positions of great respect in society. They are revered. It is hard to think of someone in AH being revered for preventing a suicide.

Fourth, physicians in training vie for positions in the fellowships that will grant them not only the ability to do good, but the ability to do well. AH fellowships are subject to much less demand even though there are fewer such positions available. It is hard for someone to choose a fellowship for three years at the end of which one will be qualified to provide services that will earn one less than one could make at the beginning of the fellowship from being a general pediatrician. Specialists in AM are generally not the major purveyors of ACHS; general pediatricians generally do that. But it is the graduates of the AH fellowships who will train the general pediatricians and give them enthusiasm for the field. As it is, however, training in AM for the primary care pediatricians is far from extensive, as training programs continue to concentrate on hospital-based services and specialties. If the financial rewards were more attractive, basic economics tells us that enthusiasm would be greater.

In sum, then, although patients might not cite financial obstacles as the key for their not obtaining services, there is a strong basis for thinking that if the field were better financed, increased utilization would follow.

What to do, then? Here are just a few suggestions, just illustrative, not definitive:

  • Change the focus of health care cost controls when it comes to AHCS. For much of medicine currently, the aim is to cut costs. For AHCS, the aim should be to increase costs. One could double or triple the cost of AHCS and it would have no impact whatsoever in the national health expenditures. Increasing expenditures would establish a better balance of expenditures and result in better health and eventually lower costs, as adult health improved and costs declined as the well-served adolescents age.
  • Change the ACA provisions for AHCS. Make all outpatient visits for teens have no deductible and only minor copays.
  • Equalize physical and mental health payments for teens.
  • Increase the requirements for AH training in all pediatrics residency programs. Introduce business case training in these programs to teach future primary care pediatricians how they can make money in adolescent health.
  • Change the Relative Value Units assigned to teen well visits – I would increase them by at least 50%.
  • Develop a set of standards for health status for adolescents under the care of larger health care institutions, and require that measurements be taken under supervision at regular times, and that the results be published.
  • Institute Pay For Performance measures specific to AH applicable for smaller practices, and require insurers to pay significant amounts to practices who achieve measures in stepped amounts according to percentile.

AH is a lot more important than people realize. There is a lot that can be improved by grants and special programs, I'm sure. But for a long lasting and relatively simple effort, I would support the basics of human economic theory – pay them more, and measure the results.

Budd Shenkin

1 comment:

  1. I can't argue with your premise: adolescent health is a vital, and overlooked, part of health care in this country. In fact, we did an entire issue of Independent Pediatrician about it ( It's difficult work.

    I also agree wholly with your second premise that adolescent medicine needs to be improved by financial drivers.

    However, I can't agree that adolescent medicine is a financial loser.

    First, pediatricians are seeing a significant slowdown in visit demand over the last 10-15 years, due primarily to the success of vaccines (yay!). There are other factors as well, though the jury is out regarding copays/HDHPs (more on that later). Still, visits are down.

    The _surest_ way for a pediatrician to maintain visit volume is to GET THOSE TEENAGERS in. More than 1/2 of them are overdue for well visits. Although there may be an argument related to $$/hour - more below - an empty exam room generates $0 revenue. And every empty room is a missed opportunity to help a teenager.

    Ignoring that considerable issue for a moment, I still don't see it on a dollar-per-minute basis. I can be more scientific later if you like, but if you correct for immunization revenue, teen well visits generate as much revenue as younger visits, sometimes more. Do they take more time - usually, we presume. But I don't know for sure.

    You can ask PCC clients to post their results on SOAPM (or give me permission to do so anonymously). 99394 visits tend to generate slightly less $$ than 99392 visits. Corrected for imms, I think there's an edge to 99394. Really.

    And getting those kids in for their well visits is how you get them properly managed for their chronic conditions, too.

    Finally, from considerable subjective experience I believe that practices who wake up and go after those teens not only fare better financially, they FEEL better as professionals. Let's not underestimate that. I am willing to bet that there's a strong correlation between satisfied practices and well visit coverage...