NC Pediatric Society Annual Meeting Day 1

Myrtle Beach is gorgeous at this time of year, or at least that’s how it looked out the window of the Marriott. After all, living in Wilmington, I can play in the surf and hunt for shells any old time, but there are only a few days a year I can spend hours in a hotel conference room full of people who do what I do and love it just as much. Here, then, is what we all heard while waves lapped at the sugary sand and palms swayed in the wind outside. Besides, we had famous author and vaccine pioneer Dr. Paul Offit inside!

Please forgive the photo quality, especially if you’re in one of them. You were all beautifully crisp and in-focus in real life. The gorgeous sunrise photo above was stolen from Dr. Ed Spence, of Charlotte thanks, Ed. One more disclaimer: I take these notes as reminders to myself and to keep me from checking Facebook every couple of minutes. They are in no way comprehensive, so if you have questions about a specific talk, please contact Steve Shore at the NC Pediatric Society or contact the lecturer directly. If you see a typo or error, please let me know, and I’ll fix it.

Finally, a request: please don't skip over the advocacy stuff. It will make a difference to us all if Medicaid payments to physicians get slashed, if CHIP funding expires, and if Medicaid gets farmed out to private HMO's without physician input or oversight. There has never been a more critical time to pay attention and get involved.

Introductions. We have people from all over the state, private, public, academic, and miscellaneous. At NC Peds, each one gets to tell us where they're from and what they're doing. You'll never feel alone in this profession again.

NC Immunization Branch 

Wendy Holmes, RN 

• New rules approved in June, to be implemented 7/01/2015.
• Rules include 2 doses meningococcal, 2nd dose varicella, 4 doses pneumococcal, etc. (see memo sent out last July for the complete list).
• Some children who have not yet had the full set of vaccines by 7/01/2015 will need catch-up vaccines.
• Vaccine storage and handling requirements will be strengthened 1/01/2015, will need back-up thermometers that has an up-to-date certificate within the last two years. This thermometer won’t stay in your primary vaccine storage unit, but to be available. Vaccine temperature logs must be documented BID, with initials, date, and time.
• Vaccine transport guidelines for taking vaccines off-site will be strengthened regarding mobile cooler, temperature monitoring device.
• Flu vaccine: around 80,000 doses have been pre-booked, shipping started two weeks ago
• Cannot borrow from one flu vaccine stock (state) and another (private) unless you also use your private vaccine for VFC children.
• Only quadrivalent vaccine will be supplied this year.
• Regional training workshops will start in October of this year in four locations in the state.
• 2-way interface with NCIR for EMR’s is still in the pilot phase, not yet ready for prime time. Pilot will be completed 12/31/2014. Being done with Allscripts now at North Raleigh Peds. Also piloting with Duke and Wake Forest. Still gathering information from these pilot sites.

NC WIC 

Josephine Cialione, MS, RD, LDN

• WIC caseload still seems down due to government shut down, enrollment problems. Please be on the lookout for families who might qualify, and refer them to WIC.
• Federal regulations now require low fat milk for children 2 and over (1% of skim).
• New regs include whole wheat bread, eggs, peanut butter and/or dried or canned beans, peas, or lentils. Fruits and vegetables have limited sodium and sugar.
• Juice must be 100% fruit or vegetable
• Formula bidding will occur again this year, may not stay with Gerber Good Start, but we won’t know yet.
• WIC promotes breast feeding first and foremost, putting resources into nursing promotion.
• WIC does not require documentation of citizenship to provide services

Updates from the Children and Youth Branch 

Gerri Mattson, MD, MPH, FAAP, NC Division of Public Health

•  Linking Actions to Unmet Needs in Child Health (LAUNCH), how to address social and emotional health in children ages birth to 8.
• Working through CCNC, pilot project in Burlington/Alamance County.
• Using early childhood mental health specialist, family centered health navigator
• Positive Parenting Program (PPP) spreading throughout the state.
• Family Centered Health Navigator uses peer support from experienced and trained parent of a special needs child to help other such families.
• 33 counties are piloting Triple P. Evidence based program around parenting and family support.
• Level 1 is changing the culture around parenting and support: Stay Positive
• Level 2 and 3 are in primary care. “light touch” intervention providing brief assistance to parents who are generally coping well but need a little help.
• Level 4 and 5 addresses severe behavioral difficulties, intensive support for families with serious problems who need coping strategies.
• Specialized Triple P includes Stepping Stones (disability), Family Transitions (divorce), and Lifestyles (overweight/obesity)
• Newborn Screening for critical congenital heart disease. Should be universal, even including home births. Should occur between 24 and 48 hours after birth. Involves pulse oximetry.
• There must be a follow up plan for positive screens.
• Also must have a reporting piece
• If a baby is getting an echocardiogram for some other reason, they don’t need to be screened.
• Medical homes need to actually see the results of the screen for follow up.

Community Care of NC Pediatric Program

Betsey Tilson, MD, FAAP

• Nearly half of all kids in NC are on Medicaid and CHIP. 75% of the CCNC population is between ages 0-20
• Children do not routinely get all recommended preventive care services, and there are long-term costs of failure to prevent, detect, and intervene.
• Backbone of the program is Children’s Health Insurance Program Reauthorization Act (CHIPRA).
• 5-year grant covering 9.2 million dollars. Improve quality measures, improve medical homes, figure out how to use EHR’s to improve care.
• Ultimately quality improvement leads to long-term health cost savings.
• Robust team working on helping practices manage issues including routine screening, quality improvement, BMI coding, lead screening, dental care and referrals, immunizations, vision and hearing, mental health issues, foster care, special needs children and youth, asthma, obesity, sickle cell disease.
• New sickle cell management guidelines issued this week, streamlined, easier to use.
• Helping to develop pediatric EHR format that vendors can use to make our practices more effective and efficient.

Medicaid Reform in 2 Minutes

Steve Wegner, MD

• Trying with NC FP group to work on creating an integrated system for NC.
• Working toward a capitated care environment. You get a lump sum, then you try to see as few patients as possible.
• Working on a physician-led not-for-profit network through CCNC to create an efficient process that best serves patients.
• Senate is pushing for private managed care companies.
• House and Governor would like to see a physician-led effort in the pubic realm instead.
• In our opinion, the House/Governor’s model is strongly preferred.
• David Tayloe, Jr. emphasizes that as pediatricians, we need to take our legislators to lunch and explain to them what we do and how a physician-led program would best serve our patients.

AAP Update

Jane Foy, MD, District IV Chair

• Poverty and Child Health is the newest Agenda for Children item. Seems too big to address, but critical to address, because we can do something in community pediatrics.
• Increasing a family’s income by $3,000 led to major reductions in obesity, hypertension, arthritis by age 30.
• Poverty rates were at their lowest in 1979 (for children). Seniors continue to see poverty rates fall, but children’s poverty rates have been rising since the 1980’s.
• We can identify family needs, connect to community resources, strengthen parenting
• Academy is working on developing a tool kit for providers with very practical ideas that we can implement in practice.
• AAP is very mindful of the pace of practice change, the new skill sets, support, and information that we will need to keep up with the changes.
• AAP is getting a new CEO/Executive Director, new Director of Marketing and Publications, new Director of Education
• Also, we have outgrown our HQ in Elk Grove Village, will be moving to a new site in Chicago in several years, planning is going on now.
• Please stay in touch with jfoy@aap.net or 336-813-0038 with any questions or ideas.

Academic Center Updates: so extensive that I couldn’t take all the notes. Just amazed to live in a state where so many people are doing so much to extend the boundaries of what we can do for child health. Major trends include growth in departments, new leadership at Duke and Bowman Gray, integrated clinics for the diagnosis of complex, challenging conditions, integration of departments to improve communication among specialists and primary care physicians.

Outgoing President Dr. John Rusher gives the Tom Vitaglione Award to Elizabeth Hudgins, our incoming Executive Director (awarded last year but never delivered)

Steve Shore accepts awards for his 15 years of amazing work as Executive Director, award of Chapter Excellence. Next to him is our new President, Dr. Debbie Ainsworth.

Steve Shore shows off his Duke jersey as he prepares for a walk-on season at his alma mater.

NC Division of Medical Assistance 

Sandra Terrell, Acting COO

• Thanks to all of us for supporting Governor McCrory’s plan for a physician-led ACO model of Medicaid reform.
• Urges ongoing communication between physicians and DMA.
• This year sees budget reductions to physician reimbursement, potential loss of Affordable Care Act increase in physician reimbursement, ICD-10 implementation.
• Statute this year proposed a shared savings plan in which physicians would participate, but this plan was repealed.
• Affordable Care Act enhanced payments to physicians: moved attestation cutoff date from 6/30/2013 to 6/30/2014 (Thank you Drs. Diasio and Barden and the NC Pediatric Society!!!!)
• Physicians who attested in time will have payments made retroactively back to January 1, 2015.
• Enhanced payments of over $107 million paid out to providers as of June, 2014.
• Attestation may continue up to December 31, 2014. Call if you have problems with attestation.
• As of now, enhanced payments will stop 1/01/2015, and physicians will be subject to an aggregate 4% rate reduction in reimbursement. Understand that this cut will be a major issue for providers. Working to address this issue with the General Assembly. Advocating to maintain adequate reimbursement for primary care physicians in our state.
• Working on the state website, trying to make it more use friendly. http://www.ncdhhs.gov/dma/bulletin/index.htm
• ICD-10 testing will begin in spring of 2015 to ensure that the go-live will run as smoothly as possible.
• Multiple questions from attendees about problems with NC Fast enrollment. Promises that the program will be working well by the end of the year.
• Answer is that eligibility is retroactive, so many families will get services paid for retroactively. Counties are working on triaging individuals to make sure that the neediest families don’t go too long without services. Call DMA if your county seems to be having difficulty responding to patients’ needs.
• David Tayloe, Jr. addresses legislation in the US Senate to extend the ACA Medicaid pay bump. Asks what the Governor might do to help encourage passage of this legislation?
• Clarification of physician pay cuts: physicians who are not participating in the ACA “bump” will be subject to a 3% pay cut, retroactive to 1/01/2014. Everyone will be subject to a 1% cut, whether or not they’re in the ACA group.
• The aggregate cut to MD reimbursement from Medicaid would be a 25-28% cut on 1/01/2014 if nothing changes.
• Question about newborns who were not properly enrolled due to NC FAST problems, now may be 6 months old. Will retroactive enrollment go back to birth, or only 90 days? Answer: they’re working on that.

Susan Mims, MD, MPH

NC Peds Annual Fund Report

I didn't take notes here, because I, too, was talking. What I was saying is that without the work of NC Peds has done in the legislature, with insurance companies, and with other stakeholders in the state, the practice of pediatrics would be much, much worse (and less rewarding) in ways that many members don't even realize. Please take a moment and give anything that you can in order to invest in the future of your practice and the children that we all serve.

The Philadelphia Measles Epidemic of 1991: Lessons from the Past 

Paul Offit, MD, FAAP

• 600 cases of measles in the US so far this year, the highest in decades.
• Classic: people go abroad, come  home, spread measles among other unvaccinated people.
• One reason that people don’t vaccinate is they’ve never seen the disease, don’t fear it.
• April 20, 1989: kid returns from Spain, attends REM concert in Philadelphia, spreads it.
• By 1978, measles cases down from 400,000 a year to 27,000. Hoped to eliminate the disease in the US completely.
• By May 19, 1990, there were 35 measles deaths in the US for that year. Led to booster dose recommendation from the CDC.
• By 12/31/1990 258 cases in Philadelphia, first death occurs.
• Then a second child died, both un-immunized.
• Example of Faith Tabernacle Church: opposed to all medical care, feels that God’s healing is the only acceptable form of healing.
• Two more unimmunized children die, both in the Faith Tabernacle church school.
• Dr. Bob Ross obtains a court order to let him visit the families. Can observe children, but cannot touch them.
• A sibling from the school dies next.
• Ross next gets a court order to allow him to physically examine the children, as parents are not telling him the truth about their health status. Team of MD’s goes door-to-door.
• Two more children die. Now one of them is from another faith healing church.
• Now 5 children have died of measles in 10 days, all avoidable. Death rate is 4/150 of the children who attend the church, or 1/35.
• CDC sends a team to investigate Finds that the strain is not especially virulent; children are dying because of absence of medical care.
• Ross now asks for court order to hospitalize children who are critically ill. Residents fan out to examine children, call the authorities if a child appears to be dying.
• Next, 2 children are hospitalized against parents’ wills.
• Now at its peak: 28 hospitalized at CHOP out of 82 seen in ED.
• Mayor asks for court order to forcibly vaccinate children as people avoid Philadelphia in droves (2/27/1991).
• Per Supreme Court, states are permitted to compel vaccination of their citizens (Jacobson v. Massachusetts, 1905)
• Confirmed in 1922, Zucht v. King
• Held until 1966, when the New York State Assembly. Bill to require polio vaccine for school entry. Passed 150-2, with the 2 being Christian Scientists.
• Only religious text that forbids vaccine is from 1877, the Christian Science book.
• Maier v. Besser 1972 opened the door to religious exemptions
• ACLU: religious freedom stops at the right of parents to martyr their children.
• March 2, 1991: court permits city to vaccinate against parents’ wishes
• By 3/9/1991, 5 children were vaccinated by the order.
• 486 church members infected, 6 killed. Attack rate about 1000-fold higher than in the surrounding community.
• First Amendment: religious beliefs may not be infringed. BUT religious practices may be infringed if they endanger the lives of children. Example: bleeding Jehova’s Witness children. Another example: polygamy. Another example: Native American church in Oregon, not allowed to smoke peyote against drug laws.
• Until 1972, it was not legal to allow your child to die from a treatable/preventable disease. Now, in effect, 42 states protect a family’s right to allow at least one child to die before the state takes action to protect the remaining children on the basis of religion.
• NC is one of the few states that does not have a religious exemption to child abuse and neglect laws. In Oregon, the law was changed, and lives have been saved.

Healthcare Transformation and Child Advocacy

Mark Del Monte, JD

Chief Public Affairs Officer & Director, Department of Federal Affairs, AAP

• AAP is the largest society for pediatricians in the world.
• Agenda for Children: Children Adolescents and Media, Early Brain and Child Development, Epigenetics, Poverty and Child Health.
• Top topics: access to care, federal funding for children’s priorities, care of immigrant children on the border, regulation of e-cigarettes, persistent drug shortages, practice transformation.
• Even though the political process is polarized and combative, the key to advocacy is to avoid becoming cynical, discouraged.
• Example of positive change: Healthy, Hunger-Free Kids Act of 2010. Did great things for pediatric nutrition in school. 90% of schools are implementing new standards without problems.
• Tom Harkin: Nothing is ever settled in Washington, DC. The fights will always go on.
• More good news: Children’s uninsured rate has fallen from 9.3% to 7.2% since 2008, a historic, all-time low!
• ACA exchange enrollment is at around 28% nationally, good in North Carolina. “Death Spiral” is not what’s happening. Age range and health status of enrollees looks good by industry standards. Also, most people pick the Silver Plan, which is not the bottom of the barrel and good again for sustainability. Even in states like NC that did not expand Medicaid saw increases in Medicaid and CHIP enrollment.
• Many people support the tenets of the Affordable Care Act while not knowing that those tenets are part of the ACA.
• People’s opinions of the Affordable Care Act are almost completely determined by their political party identity.
• People trust doctors and nurses the most (44%) about the Affordable Care Act, they trust social networking sites the least (3%)
• Next steps for the ACA: largely depends on the outcome of the November elections. Also will depend on premiums released for the 2015 plan year; so far premiums are flat or only up a little. Pricing model will reflect competition this year, now that companies have some data.
• Coming election: House is not in play, really, will stay Republican, but number of seats still matters; need 218 members to pass a bill. Senate race, on the other hand, is at risk for changing; 2008 was a great year for Democrats, so many of them are defending seats this year.
• Outcome of these races can impact CHIP program, ACA payments for Medicaid.
• CHIP is a children’s program! Refunding is going to require a concerted effort on the part of pediatricians. CHIP was a bipartisan program, developed by Ted Kennedy and Orrin Hatch, but few remaining senators remember this, and many of our champions are retiring.
• Governors like CHIP. Very helpful for state governments.
• Remind Senators that CHIP is not part of the ACA, not part of the whole health care reform debate.
• CHIP is S.2461.
• Other bill is Ensuring Access to Primary Care for Women and Children Act (S.2694), would extend Medicaid payment increase for 2 years. Good bill, endorsed by AAP, AMA, AAFP, ACP, ACOG
• We are going to have to work hard in conjunction with all of our state medical societies and talk repeatedly with our Senators and Representatives.
• federaladvocacy.aap.org Go there!!
• VOTE! If you don’t, then your influence with your legislators will be diminished.
• Election time is a great time to ask your legislators for stuff. They want your vote. Discuss the small business angle and the need for you to be able to care for these kids. Other states are putting up the money themselves, including several Southern states; feel free to mention that.
• E-cigs. Critical to address poisoning risks. Also seeing nicotine addiction threatening to become cool again after all of our work. Regulations remain on hold for now. AAP working hard on this issue. Relate your stories to Mark if you have them.

Grand Theft Auto Rounds: A Discussion on Video Game Influences in Children 

Zachary T. Burroughs, MD (WF) 

• What makes a video game violent or explicit? Violence, Gore/blood, Language, Nudity, Gambling
• There is a wide range of realism for each of these contents
• First violent video game: Death Race 2000 (1976), running over gremlins with a car (not humans, right?)
• Next, Custer’s Revenge 1983 on Atari. Naked Custer figure attempts to rape a Native American woman tied to a pole.
• Next, Mortal Kombat (1992) arcade game, jumped to home consoles. Graphics were much better, lots of blood, ripping out hearts, ripping off heads. Awarded for fatal wounds to others.
• Night Trap (1992), slumber party of scantily clad women endangered by vampires.
• Doom II (1994) first person shooter, lots of blood, you’re behind the gun.
• Ethnic Cleansing (2002) invites players to fight their way through a city of blacks, latinos, and jews, whom they must kill. Victims cry out racially inspired cries on dying.
• Grand Theft Auto (1998), lots of blood, realistic graphics, explicit sex within the game. Initially pulled from retail shelves. Rockstar Games has been sued many times.
• Manhunt (2003), many different ways to murder victims, from suffocation to axe murder.
• Virginia Tech Rampage, Super Columbine both role playing games.
• Call of Duty, highly realistic first-person shooter.
• Entertainment Software Rating Board. Established in 1994 as self-regulatory organization. Assigns age and content ratings to video and computer games. Grew out of Congressional hearings, threat of regulation.
• Two tiered system with 6 age-based ratings, 32 content descriptions. Early Childhood, Everyone, Everyone 10+, Teens, Mature 17+, Adults Only 18+.
• An E10+ can have some violence, suggestive language. Teen rating includes partial nudity, blood, suggestive themes. 
• Mature rating cannot be sold to minors, need a photo ID. Many parents and sibs buy these games for younger children.
• Adults Only include graphic nudity, sexual content, potentially real gambling, drug use (the three major platforms forbid AO games being made for them).
• Ratings are not legally binding, but many retailers will only stock rated games. ESRB enforces responsible advertising practices, may restrict where previews or advertisements may appear.
• How do games get rated? First the ESRB is sent a DVD including the most graphic content in the game, also a questionnaire. They employ trained raters to recommend a rating. Publishers may edit, file an appeal if they don’t agree with the rating. Then the game is play-tested, packaging is evaluated.
• M for Mature: example, Grand Theft Auto V. Players may use pistols, machine guns, explosives to kill enemies and innocent civilians. Depicts fellatio, masturbation, sex acts from a prostitute. Players may use cocaine or marijuana. Words in the dialog include (just imagine, here). Necrophilia is included in this game. Lap dances can be purchased during the game.
• Another symbol: Users Interact. This means that players can interact on message boards, in-game chat. Other players may get the user’s physical location. Chat may be text, audio, or video. Players may generate worlds or costumes not published by the game maker.
• Per AAP Policy (2009): Media violence leads to aggressive behavior, nightmares, desensitization to violence.
• Australian study (2012) demonstrated 27 minute decrease in adolescent sleep time, decreased sleep efficiency with prolonged play of a violent game.
• Pediatrics 2008, Craig Anderson et al: reliable and predictable relationship between aggressive video game playing and aggressive behavior, even in cultures like Japan with low levels of physical violence, affects both boys and girls.
• Carnagey et al 2006: physiologic response to real-life violence diminished, desensitized.
• Desensitization leads to decreased willingness to help in real life, increased aggression. Exacerbated when games reward violent acts with points, music, other rewards.
• AAP Recommendations: Keep screens out of the bedroom, limit screen time to 1-2 hours per day, don’t buy violent video games for kids, especially if killing is rewarded.
• ESRB website provides lots of useful links, advice for parents. http://www.esrb.org/index-js.jsp Shows you how to use parental controls on various game consoles. 
• Tips for parents: check ratings and reviews, set parental controls, be vigilant and monitor games, speak up and be involved (can alert game publisher and report bullying or inappropriate content from player accounts), set limits, teach kids not to disclose personal details to other players, keep the game console out where you can see it, be aware of the risk of cyberbullies (anxiety and depression, withdrawal, changes in computer use)
• Do include game discussions in your anticipatory guidance.