Why kids wait months for specialty care

Parents are waiting a long time to get certain types of specialty and subspecialty appointments for children.

In some cases, kids are waiting 20 weeks, or longer, for certain pediatric subspecialty appointments, according to a report from the Children’s Hospital Association. Families typically wait 14 weeks for a pediatric neurology appointment.

So that means even when a child’s need has been identified, they are waiting months, or almost half a year in some cases.

Matt Cook, CEO of the Children’s Hospital Association, tells Chief Healthcare Executive® that it’s a persistent problem. He dealt with it years ago as president of UCSF Benioff Children's Hospitals and Riley Children’s Health.

“Even back in a couple of the hospitals that I ran, we had those types of wait times,” he says. “And it really is about the shortage in certain specialties.”

Some of the most glaring shortages are in developmental pediatrics, he says.

“There just aren't enough providers to meet the demand, and what that means at the end of the day is that when you have a parent who is trying to bring their child for a new visit, it can literally be half a year,” Cook says. “It can be six months, and that's true for some of the other specialties as well.”

Mental health needs

Children are waiting longer for behavioral health services due to a shortage of clinicians, and that’s a problem across the country.

Roughly three of four U.S. counties (72%) do not have a practicing child and adolescent psychiatrist.

“it is really a striking number when you consider the challenges we have in this country with mental health and the fact that the crisis has been getting worse over the last several years,” Cook says.

With so many counties lacking a psychiatrist trained in serving kids and teens, he says, “that also explains, then, the wait times for that specialty, and why parents are really struggling to get their kids seen.”

Even those fortunate enough to live in a county with a child psychiatrist may find barriers to getting the care they need.

“Even if you have a child psychiatrist, you still may have issues with insurance coverage and what that child psychiatrist accepts,” he says. “There are psychiatrists that only accept cash, that do not accept insurance or may not participate in the Medicaid program. So those are layers on top of that statistic, and it's really pretty troubling.”

Planning for Medicaid cuts

Children’s hospitals rely heavily on Medicaid. Over half of the patients in pediatric hospitals are covered by Medicaid, but Cook says Medicaid reimbursements don’t cover the full cost of care.

As a result, pediatric hospitals struggle with recruiting doctors and nurses, and keeping them.

“For most children's hospitals, well over 50% of their patients are Medicaid,” he says. “It's not uncommon to have children's hospitals where 70% of patients are Medicaid. Medicaid is the largest insurer for children's health care in this country, and so it just magnifies the impact of the workforce shortage.”

With cuts in Medicaid coming over the next several years due to the HR1 tax package signed by President Trump last year, children’s hospitals are going to see more financial challenges. States are facing changes in the way they finance Medicaid programs.

The Medicaid changes don’t call for any reduction in coverage for children, but pediatric hospitals may see less support from Medicaid, Cook says. That will pose additional financial headaches for pediatric hospitals that are dependent on Medicaid, and it could add to staff shortages.

Some of the impacts won’t be felt for a few years, although he says states such as California and Washington are already seeing issues with supplemental funding programs.

Pediatric hospitals are making plans to deal with less support from Medicaid.

“Children's hospitals are preparing for that, and so they're already making financial decisions today based on this expectation that implementation is going to carry forward and there is going to be a financial impact,” Cook says. “So they're already looking at ways to reduce costs. And I think that is problematic, because we'll see how much that impacts in terms of access to care, and where services are. But certainly in states like California and Washington, we're already seeing a financial impact.”

Medicaid is a federal-state partnership, and the Trump administration has indicated it wants states to play a bigger role in supporting Medicaid, Cook notes.

“The challenge with that philosophy is that 43 of our states have balanced-budget requirements, and so if you can’t within your budget absorb increased funding for Medicaid, either you don't do it, or you have to turn around and cut services somewhere else in your state budget, or raise taxes. And none of those are politically feasible either,” Cook says.

“So I think it really puts states in a very difficult position to figure out: how are they going to preserve funding to the Medicaid program, when they do have budgetary concerns in other areas? And I think that really is probably an unintended consequence of HR 1.”

With less Medicaid support, patients could see longer waits for services in the future, he says.

‘Tough to entice people’

The shortage of pediatric doctors has been building over time, and Cook says there isn’t a quick fix.

“Medicaid is a really low reimburser for healthcare services, and the downstream impact that that has is not just on the hospital's financials, but it does also impact the compensation for physicians,” he says.

Doctors in pediatrics also train longer than some of their counterparts treating adults. Given the longer period of training, doctors get discouraged working for lower pay, and pediatric hospitals struggle with retention.

“From a rational argument perspective, that's kind of tough to entice people into a field where they're going to train longer and make less money,” he says.

Cook would like to see the federal government provide more support for the Children's Hospital Graduate Medical Education Program, which could help increase the supply of doctors in pediatrics. The program received a $5 million increase in the federal budget package approved in February.

But he says the program is “highly underfunded” compared to the Medicare Graduate Medical Education program. The children’s hospital education program receives around 38% of the funding that the Medicare graduate medical education program provides for training.

“It puts this incredible burden on children's hospitals to bear the financial brunt of training the workforce of the future,” Cook says. “And that's just not sustainable.”