Ohio AAP 2020 Annual Meeting Q&A Follow-up

Ohio AAP 2020 Annual Meeting Q&A Follow-up

Link to slides/handouts and videos

2021 Coding & Billing

Will new administration have any effect on CMS, codes, etc.?

I would not anticipate any significant changes with the current administration to the current E/M coding changes, or to those in the works. CMS, however,  could be affected by any changes to the Affordable Care Act, which we hope will stay largely the same. We can always hope for Medicaid to Medicare payment parity, which the AAP will continue to promote. In summary, any changes we hope will be positive relative to access to care and payment for services

Store it Safe Teen: Suicide Prevention

Are there any AAP sponsored initiatives for minorities? The suicide rate is especially disparate in Black and/or LGBT adolescents.

National AAP and each chapter have appointed a diversity and inclusion champion. We review every Ohio AAP program to see how minorities and underprivileged children/adolescents are affected. The Store It Safe (SIS) program is a widespread message to all adolescents. We are encouraging teens to visit their pediatrician for preventative care and to insure a medical home. During these visits, we are asking all adolescent providers to screen for depression and counsel about firearm safety. In addition to medical providers, we are hoping to have community organizations that work with teens to refer them to their pediatrician and also to spread the SIS message. The goal of the program is to get all teens, despite SES or minority status, to be screened for depression and store firearms safely.

What are your perceptions of student depression, anxiety during this pandemic, how can we connect/be available to struggling students?

It is clear that depression and anxiety have increased during these COVID times. Psych evaluations in emergency departments have seen a large increase. However, our message is still the same, frequent depression screening is essential and services should be sought when needed. We need to be encouraging all firearms (and medication and alcohol!) be secured safely when a teen is in the home. While there is no one size fits all solution for all teens, the below information may be helpful for parents and caregivers.

  • Get to know your students. Although this sounds obvious, it isn’t always easy. Teens can be quiet or not want to talk to adults.
  • Know the risk factors.
  • Since teens are impulsive, a barrier to lethal means by locking up medications, alcohol and guns from teenagers can be highly successful. Encourage families to keep firearms safely stored. Making firearms inaccessible to a teen has been shown to significantly reduce the completion of suicide, in some studies by as much as 73%.

Are there resources for parents with anxiety and depression for helping their children with anxiety and depression and suicidal thoughts?

Our SIS resources are for parents and teens about depression and firearm storage. We recommend parents suffering from anxiety and depression see their primary care provider.

Federal Affairs

What do you think are the most likely changes in coverage and access in the upcoming White House and Congress?

Sweeping change is unlikely, but the change in the administration cannot be overestimated; for example, if the CMS seeks to ensure every child who is eligible is enrolled in Medicaid, the Cabinet and heads of agencies will matter and this will have to be built. The AAP could be influential in helping advise the new leader and a Biden administration could work administratively to shore up the Affordable Care Act.

What do you think the federal mandate on pharmacists will lead to? 

The role of chain drug stores has been large during this administration and will be important in COVID-19 vaccine distribution; however, we will continue to advocate for pediatric medical homes and the role of pediatricians in vaccine provision.

State Advocacy Update

When and how will redistricting be processed after the census? Will it help the gerrymandering?

There are two processes that are undertaken after each decennial census to redraw Ohio’s legislative maps. Reapportionment is the process by which districts for the Ohio House of Representatives and Ohio Senate are drawn. Redistricting is the process for drawing Congressional maps. In recent years, Ohio voters opted to modify both processes to create more input from the Minority Party in state government, which is currently the Democratic party. The goal of these reforms was to address gerrymandering. Each process would require more support from Democratic legislators and would limit certain map-drawing practices (i.e. packing, cracking) to try and create more balanced districts. These processes will begin next year. Given that this is a new process, it is difficult to speculate about the outcome. Most experts seem to think that Republicans can continue to maintain their dominance and craft friendly maps, though they won’t be quite as gerrymandered as they currently are.

COVID-19 Vaccine

 What is the youngest age that will be able to receive any of the COVID-19 vaccines? 

Currently, the youngest is 12 years of age. However, we have been sent protocols from 2 different Sponsors with the age going down to 5 years of age. Some companies have talked about going down to 12 months or less, but I have not seen those protocols yet.

Any thoughts or predictions on WHEN we will start vaccinating kids?

The clinical trials for children likely will start in late Winter- early Spring. As for children we are doing “Immunological bridging studies”, the numbers will be smaller and results available sooner (maybe within 2-3 months of enrolling).Thus, I still think it possible that we will have licensed vaccines for at least some pediatric age groups before the 2021-2022 school year.

What about patients who have tested positive whether symptomatic or not OR have positive antibodies – is there a plan whether they will be able to get the vaccine?

Good question. That still needs to be decided. From small scale studies in adults, the frequency and type of side effects were the same whether or not you had already had COVID-19.

I am a vaccine trial participant. Will they inform placebo recipients so they can get the real vaccine? 

That is the plan I have been told. I have not seen final plans, but I am confident that vaccine trial participants who received placebo will be offered the vaccine.

Where do Pediatricians fall in this distribution?

I think all health care providers seeing patients are seen as a single category. However, the final decisions will be coming from the State Health Departments. Some of the decision will be based on how many doses of vaccine we have.

When will they use this same vaccine technology to come up with a universal influenza vaccine?

That would be great! One thing in favor of the COVID-19 vaccine is that the spike protein seems to be essential to the virus. The essential protein for flu looks to be the stalk protein. However, it has been difficult to get a good antibody against the stalk protein. Maybe the new technologies will improve our ability to make vaccines against the stalk protein.

What about the very low temperatures that are needed to keep the vaccines stable? 

Pfizer told me that they are currently looking at the stability of the vaccine at warmer temps. My guess is that we will find that the Pfizer vaccine will have storage requirements similar to Moderna. However, we need to test to be sure.

What temps ae needed for vaccines? 

 Currently, Pfizer is listed as -70C while Moderna is -20C. Astra Zeneca is refrigerated. I think companies will be looking at the ability to safely store the mRNA vaccines at warmer temps. I think there will be a workable solution as to the storage requirements.

How do you recommend talking to families about potential long term risks that can’t be known yet due to the vaccine creation timeline?

All the vaccines are targeting the spike protein. The mRNA vaccines are using mRNA that is degraded soon after it is translated into spike protein. So, there should not be any long term effects of the mRNA. The Astra Zeneca vaccine is using an adenovirus that is replication incompetent, meaning that the virus can’t live and grow in us. The Sanofi and NovaVax vaccines are protein vaccines, very similar to the flu vaccine. The end result is that while the technology is new, there is no evidence to indicate there is long term harm from the vaccine candidates.

Are you concerned about how polarized the public is about all science especially prevention including vaccines?

I am concerned about the general breakdown in the trust of science and how Public Health measures are being viewed as political issues instead of safety issues. However, we need to keep up the fight and continue to be strong advocates for the health of children, particularly preventive medicine such as vaccines. If we don’t keep up the campaign to educate and inform parents, we will be putting the health of children at risk.

Top 10 Articles that Change the Way You Practice

 Are there any evidence based interventions that have effectively changed anti-vax parents’ opinions?

It is (of course) really difficult to change entrenched opinions.  One strategy is to increase vaccination through health policy.  Here is an article about vaccine exemptions in California.  However, how we discuss vaccination can have a powerful impact on what patients and families decide to do.  Here is an article on announcements vs. conversations – I think this is a helpful example of what can be done.

Some counties have drug drop off sites at police and sheriff stations for envelopes, but these may not be secure. How do we stop those envelopes from being stolen?

I think this is a better question for the drop-off sites.  However, the key issue is that removing unneeded opioids can protect from ingestion.  There are many examples of accidental ingestion (poisoning), use in suicide, or for other uses.  So, this kind of removal is an important strategy.

Financial and Legal Fitness

What % can I take out each year for retirement?

The data suggest that if you have a diversified portfolio of stocks, bonds and cash you should be able to withdraw between 3 and 5% of the portfolio value.  Of course this depends on many factors and could be more or less depending on the portfolio.  Rebalancing and making changes to the funds will also be significant factors to weigh.  Remember, withdrawing money from a portfolio creates downward pressure on the value and there may be years where the portfolio finishes the calendar year lower than where it began.

How would you recommend trainees prioritize Roth IRA versus employer accounts during residency/fellowship?

Always take advantage of any matching from the company, if you will be with the employer long enough to get through the vesting period.  If your tax rate is low and you are able, the ROTH IRA will give you the best long term outcome because the account grows tax deferred and if you meet the criteria, all monies will come out tax free.

Concerning malpractice in locum tenens contracts, do we have to have in writing that we are not responsible for tail coverage or do we need to specify it if they don’t say we are responsible for it?

Malpractice in locum tenens contracts, as with other employment agreements, the physician should try to ensure there is language stating that the physician will NOT be responsible for tail coverage (either that the malpractice insurance will not necessitate tail coverage, or that if the insurance coverage provided necessitates tail coverage, the employer will pay for such coverage).