00:00There's a published article out there now that says that 50 percent of revenues to most pediatricians come from from vaccines.
00:11The claim is headline grabbing, but it's not backed up by the facts.
00:15It turns out that far from being a profit center for pediatricians, vaccinating children is a loss leader or maybe simply a loss.
00:23I think it's really hurtful that the narrative around pediatricians profiting from vaccines continues to be put front and center.
00:32Pediatricians actually have to work extra hard to make sure that they can have all the vaccines on hand in their clinic settings and to be able to afford that.
00:44The business of vaccination is particularly expensive, not only because doctors need to buy the vaccines to have them on hand, but also because of the equipment to keep them.
00:54Dr. Ben Hoffman is a professor of pediatrics at Oregon Health and Science University in Portland and the past president of the American Academy of Pediatrics.
01:04Being able to procure, store and deliver vaccines in a clinical setting is a really complicated endeavor and it requires resources within the clinical setting to order vaccines, whether it's from the manufacturer or a broker or from the state.
01:25The practice has to purchase X number of doses of a vaccine, put it in storage and over time hope that that they will give enough of the vaccine so that they make back the money they spent.
01:42So pediatricians stretch their finances to be able to have all those vaccines on hand for their patients, for the convenience and because they know how important it is.
01:52The cost of buying and administering vaccines has been a pain point for years.
01:58In a 2017 study, 12% of pediatric practices and 23% of family medicine practices reported that they stopped buying at least one vaccine because of the cost.
02:09Dr. Sally Permar is pediatrician-in-chief at New York Presbyterian and chair of the Department of Pediatrics at Weill Cornell Medicine.
02:18So the field of Pediatrics has really changed to the better of healthier children, fewer coming into the hospital, fewer with diseases that left them with disabilities and other illnesses so that we know the value of vaccines.
02:34But we're left with cleaning up all of the misinformation that is really dominating the fields these days.
02:42Even here in New York, we had over 90% of our families getting all of their shots by age five.
02:50At this point, and even just in the last year, it's gone into the 80s.
02:54And it's putting not only our children at risk, but really all of us at risk.
02:59The challenge of providing children with the health care they need goes well beyond vaccinations.
03:04It's one piece of a larger picture in which pediatricians systematically are paid less, on average, than other specialists.
03:13It actually is a tough job to keep a pediatric practice afloat.
03:19Pediatricians are some of the lowest paid of all physicians.
03:23In fact, they're paid 30% lower, on average, than that of adult specialists who had the same number of years of training, the same amount of debt.
03:32We know that the bigger system really does not value the health of kids in the way that it needs to.
03:39Yet, we're working to address child health in the field of pediatrics on a playing field that is completely rigged and exists to support the fiscal incentives around adult health.
03:57What are those financial incentives that favor health care for adults over children?
04:03First and foremost is the way that the federal government reimburses physicians for what they do.
04:08Medicare pays providers like doctors and hospitals typically less than private insurance, but typically substantially more than Medicaid.
04:17Catherine Baker is provost at the University of Chicago, former dean of the Harris School of Public Health, and an expert in the economics of health care.
04:26Medicaid is a partnership between the states and the federal government, and Medicaid reimbursement rates for physicians and hospitals vary a lot, state to state.
04:36And that really affects whether patients who are covered by that insurance program have access to providers in that state.
04:43That difference between Medicare and Medicaid translates into a difference between how much we pay for the health care of the elderly and the health care of children.
04:51As of June, children comprise nearly 48 percent of enrollment in Medicaid and the Children's Health Insurance Program, or CHIP.
04:59Medicaid pays at about 30 percent lower for their reimbursement compared to Medicare, which is available to all adults over 65.
05:08And in addition to that discrepancy, there is how we value health care, and in particular, preventative health care and even children's health care is often valued at a lower level, which translates into the reimbursement.
05:24So, for example, a pediatric visit, 30 minutes with your primary care provider to do things like injury prevention, obesity prevention, vaccines, is valued at about a tenth of an orthopedic procedure that may take the same amount of time.
05:44The fact that Medicaid pays so much more poorly than Medicare translates both to payment that pediatricians receive from Medicaid but also from commercial insurance.
05:55In most circumstances, commercial or private insurance will pay more for the same service than Medicaid will.
06:03And as a result, it can be challenging for a lot of pediatricians, especially if they're in private practices, to be able to balance their books if they're seeing a significant portion of patients who have Medicaid just because the payment is so much less.
06:21The disparity in health care between the young and the old, in reimbursement and in income, can discourage doctors from pursuing the specialty of pediatrics.
06:30If you're a medical student looking at the range of careers that you could have after medical school, you're going to put potential salary, earning potential, in that consideration.
06:45And what has grown over time is, of course, our debt, not only starting at the undergrad level, but also at the medical school level.
06:55So education debt can be in the hundreds of thousands for new physicians that are just finishing.
07:01And that would be the same no matter what specialty you're choosing.
07:04So we are facing a pediatric workforce crisis that has been growing more severe over the last decade.
07:11In fact, we've lost 20 percent of the number of U.S. medical grads that used to go into pediatrics don't choose pediatrics anymore.
07:19Beyond discouraging the next generation of pediatricians, the economics are also driving some out of the practice.
07:26The jobs for the families are few here.
07:30So the income base is low and a lot of the families are on Medicaid services here.
07:40Dr. Jill Neff had her own practice in southeastern Ohio for some 30 years.
07:45I did close my practice and it took me two years to come to terms with the thought that I had to do it.
07:53It's an extremely hard decision.
07:56I feel like I am leaving them, that they have nowhere to go, that they've depended on me.
08:02And yes, many tears, many discussions.
08:07It's extremely hard.
08:08If the math of running a practice and getting paid for it isn't working well in cities, the problem is even worse in rural areas.
08:16I did talk to one of my representatives a couple years ago on this topic and asked him, you know, is there some way, some way at all that the government can help do this?
08:28And his response was, well, the communities need to come together and come up with the money themselves to pay these physicians to come there.
08:34This town cannot come up with money to pay physicians to come here and pay off their hundreds of thousands of dollars of debt.
08:45If we are committed to ensuring our children receive all the health care they need and deserve, what has to change?
08:51Those who know best, the pediatricians, see a pressing need to reform the system.
08:57They say there's a long way to go to live up to all that we say about caring about the future of the youngest among us.
09:04So the first thing is advocacy.
09:07We need parents, grandparents, people that were once children, and that is all of us, to know about this and to talk about how this isn't the way that we think as a society.
09:23We all value children.
09:24We have children in our family that we, our families and outside our families that we know and love, but they're not being prioritized in our health care.
09:32And so one is just the knowing about the problem and advocating then how can we, at a time that we're seeing a lot of change in health care and how our government funds health care.
09:43And when we come out of this crisis that we're in as a government about health care, can we emerge with new priorities that includes investing in health at the earliest stages of life for improving the trajectory of health across the whole lifespan.
10:01So that's a big one to me is advocacy and what can we do with our policies, but the next is shifting some of the priorities of how health care has always been funded.
10:14Can we think differently about how compensation is determined so that we can have some high revenue earning areas spread to other areas that are more underfunded?
10:29So that that's a harder one, but one that we should think of as hospitals and health systems.
10:33Advocacy, changing the metrics, engaging not just the government, but also philanthropy, reforming the system will be a tall order, but the stakes could not be higher.
10:45One of the things I think is really important for people to realize is that while kids make up 30 percent of the overall population, they are 100 percent of our future.
10:54And I mean that in terms of our economic future and our security future, cobbling together something in with the crumbs or what's left over from the adult health care system is not going to work.
Comments