North Carolina project aims to shorten wait times for pediatric subspecialists

A child in North Carolina typically has to wait nearly two months to see an endocrinologist, three months for a gastroenterologist and nearly a year for a rheumatologist, according to a recent survey that looked at the appointment calendars of pediatric subspecialists in the state's academic medical centers.

That's longer than many children with special health care needs can afford, said Alan Stiles, MD, chair of the Pediatrics Dept. at the University of North Carolina, Chapel Hill. "Any child who has a serious chronic illness and has to wait 45 weeks [to see a specialist] is probably going to end up in the emergency room," he said.

The problem is that pediatric subspecialists are in short supply. There are only five pediatric rheumatologists in all of North Carolina, according to the survey, conducted by the Maternal and Child Health Policy Research Center. That's just one rheumatologist for every 237,102 children. Similarly, there are just nine pediatric gastroenterologists and 19 pediatric endocrinologists.

The shortage of pediatric subspecialists is not limited to North Carolina, but is a nationwide crisis, according to pediatricians and experts who study children's access to health care.

But what is unique to North Carolina is the approach that its physicians, teaching hospitals and Medicaid program have developed to address the problem.

They recently launched a public-private collaboration aimed at making more efficient use of pediatric subspecialists by improving communication and coordination between them and primary care physicians.

The goal of the pilot program, called Improving Pediatric Access through Collaborative Care, is to provide primary care doctors with better information and support from pediatric subspecialists so they can treat more children with special health care needs themselves and reduce referrals whenever possible.

"It's something we absolutely need to do," said Charles F. Willson, MD, president of the North Carolina Medical Society and professor of pediatrics at the Brody School of Medicine at East Carolina University in Greenville.

The idea is to provide chronically ill children more timely care -- at their medical home -- so they don't have to wait months for an appointment with a specialist and travel hundreds of miles to an academic medical center.

Program officials hope that will improve the children's health outcomes and reduce their emergency department visits and hospital admissions, said Dr. Stiles, who is the pilot program's principal investigator.

The project's backers -- which include state Medicaid officials, academic medical centers and the medical society -- also hope it will reduce unnecessary referrals and free up subspecialists' time so they can see new patients more quickly and can focus on patients who most need their care.

"It's brought about by the sheer fact that there are too few pediatric subspecialist physicians to meet the needs of the children of our state," said Dr. Willson, also past president of the North Carolina Pediatric Society.

A fresh approach

The project, which was formally launched in August, will use several strategies to improve both the communication and the coordination between primary care physicians and pediatric subspecialists.

One is to begin paying pediatric subspecialists for telephone consultations with primary care physicians -- a practice that is relatively unusual for both Medicaid programs and private insurers.

But the North Carolina collaborative believes telephone consultations are worth paying for, said Steve Wegner, MD, who heads the new program and is president of AccessCare, a network of primary care physicians that serves Medicaid patients in North Carolina.

"We think that if we can pay the specialist for that phone call, then oftentimes they will be able to help the primary care doc handle that patient at home, in the primary care practice," Dr. Wegner said.

Initially, the program will pay about $30 for each consultation, but the amount may increase to about $50, depending on the feasibility, Dr. Wegner said.

A nonprofit foundation affiliated with the state's Dept. of Medical Assistance has provided $300,000 for that part of the pilot program.

The project also will hire more case managers to do a better job of linking pediatric subspecialists at academic medical centers to the primary care setting.

The state Medicaid program is putting up $821,000 in the first year of the pilot program to add 14 new case managers at academic medical centers. Their role will be to coordinate with case managers who work for the primary care physician networks that serve the Medicaid population in North Carolina.

The success of this approach was demonstrated in a pilot study in North Carolina in 2005 that focused on children with type 1 diabetes, according to Ali Calikoglu, MD, associate professor of endocrinology at UNC.

The study, led by Dr. Calikoglu, enrolled, for six months, 51 children with poorly controlled hemoglobin A1c levels. At the end of six months, the average A1c levels of children in the intervention group dropped from 10.4% to 9.5%, while the level for children in the control group dropped from 9.9% to 9.7%. The difference in the results is both statistically and clinically significant, Dr. Calikoglu said.

The program also will convene doctors in each of the pediatric subspecialties to develop appropriate guidelines and protocols that primary care physicians can use as a tool to help them with treatment and referrals.

Taken together, the project's strategies could serve as a model for other states, said Peggy McManus, co-director of the Maternal and Child Health Policy Research Center, a nonprofit group in Washington, D.C.

"There's nothing comparable to what's going on in North Carolina in any other state," McManus said.