Restrictive health-insurance policies and the high debt incurred by medical students will adversely affect the way health care is provided to children, a panel discussing the future of pediatrics said here last week.
Participants at the session, held during the annual convention of the American Academy of Pediatrics, said the changing demographics and economics of their specialty could lead to poorer-quality health care for poor and working-class children in coming years.
The root of the problem, several physicians at the session said, is that the nation’s approximately 40,000 pediatricians, like their peers in internal medicine and family practice, are on the lowest rung of the profession’s pay and prestige ladder.
Although pediatricians spend more time than specialists do providing primary care to patients, participants said, insurance companies pay specialists higher reimbursements for their extra training and expertise.
Further clouding the payment issue is the growing number of children who are either uninsured or are enrolled in Medicaid. About 12 million children have no insurance at all, and 11 million are on Medicaid, which provides only modest payment to doctors for regular “well care” visits.
“The very best pediatricians, except in communities where you can afford ‘boutique’ care, can’t afford to spend the time they need with patients,” said Louis Z. Cooper, a professor of pediatrics at the Columbia University medical school. “But if you are taking care of ordinary, working-class families, you aren’t getting the payments from insurance companies and Medicaid you deserve.”
Financial Disincentives
Panel members also said they were concerned that, in the future, medical students will not be able to afford to enter pediatrics, further limiting the quality and quantity of doctors for young children and adolescents.
Although about 9 percent of all medical graduates continue to enter pediatrics each year, many observers are concerned that the relatively low pay pediatricians receive will persuade students to choose other specialties. The starting salary is about $10,000 a year less than in other primary-care fields.
According to figures released at the meeting, the average total debt for new doctors is $47,000, and much higher debts are not uncommon. Yet, said Russell W. Chesney, the Le Bonheur Professor and chairman of the pediatrics department at the University of Tennessee’s Memphis College of Medicine, students who have debts that exceed $60,000 cannot afford to become pediatricians, even with an average starting salary of more than $55,000.
Dr. Chesney said that when he finished medical school in the 1960’s, “The top students went into internal medicine and pediatrics. Today, top students go into otolaryngology [ear and throat disorders] and radiology to pay their debts.”
Doctors who do enter pediatrics are more likely to choose a subspecialty than they were in the past, thus allowing them to receive higher medical reimbursements, doctors at the sessions said. But pediatric specialists, they said, are less likely to handle primary-care patients.
Some at the session also said they were concerned that an academic career, which is less lucrative than private practice, may also become less popular. This, they said, could have long-term implications for the development of new pediatric treatments and for basic research on many common childhood diseases.
Antoinette Parisi Eaton, the immediate past president of the A.A.P., said she believes that pediatrics is still seen as a viable career path for new doctors, especially for women, who make up more than 50 percent of all new pediatricians. “I don’t think we are seeing a problem, despite the debt problem,” she said.
A Changing Practice
Those who overcome the financial disincentives of pediatrics and enter the field often find that the policies of insurance and health-maintenance organizations make it increasingly difficult to provide high quality care, some of the physicians at the panel discussion said.
Since primary-care doctors are supposed to act as “gatekeepers” under many of these payment schemes, some at the session suggested, children may not be referred to the best specialists for care. And since many decisions at H.M.O.'S are guided by economic interests, they said, this could lead to interference in the traditional doctor-patient relationship.
“Over the next few years, we are going to see increased control over the practice of medicine,” said Betty A. Lowe, a professor of pediatrics at the University of Arkansas School of Medicine and a co-author of a report released last spring that served as the starting point for the group’s discussion.
Not only have the economics of pediatrics changed, but the nature of a pediatric practice has changed as well, the doctors said. Twenty or 30 years ago, they observed, most pediatricians spent much of their time on typical childhood problems, such as the measles, broken bones, and high fevers. But in recent years, what have been called the “new morbidities"--including teenage pregnancy, preventable injuries, and drug and alcohol use--have come to the fore, they noted.
Many of these problems, the doctors said, probably can be traced to the same social conditions that have led to the dissolution of the nuclear family in many households. But without this traditional support system, they said, children’s problems are even more difficult to treat.
As a result, pediatricians now routinely face issues they never had to deal with before on a regular basis, such as cholesterol screening, smoking-cessation programs, and prescribing birth-control pills for young girls.
“I entered pediatrics with the idea that I would never have to face these things,” said Dr. Chesney.
