Family Advocacy Day

DrMandellDear Readers,

I am so pleased that Children’s Hospital Boston will be so well represented at Family Advocacy in Washington, DC this year. I have had the pleasure of attending Family Advocacy Day in years past, and I am certain that our six patient families will have a tremendous impact on Capitol Hill.

It is important that we take advantage of every opportunity to advocate for children and Family Advocacy Day is one of our most valued opportunities. The timing of this year’s trip is excellent, as Congress works toward passing national health reform legislation. Children and children’s hospitals have a lot at stake in this debate. From increasing the numbers of children with health insurance to ensuring a stable, high quality pediatric health care workforce – the possibilities to improve children’s health care are great, but only if we work together to educate those who write the laws.

Children’s Hospital Boston is proud to support this advocacy effort because we know that nothing compares to a story told firsthand by our patient families. I wish you all a safe journey, productive meetings, and an empowering experience.

Please click below to view a letter sent to Senator Kennedy outlining our priorities in health reform.


James Mandell, MD
CEO, Children’s Hospital Boston

June 15, 2009

The Honorable Senator Ted Kennedy
U.S. Senate
317 Russell Senate Office Building
Washington, DC 20510

Dear Senator Kennedy,

A critical measure of success in Congress’s current efforts to reform our nation’s health care system will be whether the final legislation builds upon the strengths of our current system and reforms other areas to improve the quality, access, and affordability of care for children.  As we at Children’s Hospital Boston are closely monitoring the developing proposals in Congress, I present the key issues for pediatric hospitals below and ask that you keep our needs in mind as the debate continues.

Preserving the Community Mission of Children’s Hospitals

Children’s hospitals comprise only 3 percent of all hospitals nationally, but provide more than 40 percent of hospital care for children.  In comparison to those in the adult field, pediatric providers care for a particularly high concentration of Medicaid enrolled patients.  While federal and state efforts to ensure coverage of all children have resulted in an impressively low rate of uninsured children in our region, shortfalls in Medicaid reimbursements result in significant losses at Children’s Hospital Boston. 

As the backbone of children’s care, children’s hospitals provide community benefits in a myriad of ways.  Children’s hospitals serve a unique role contributing to their communities in many ways not captured by a simple definition based on charity care provided to uninsured patients.  For example, at Children’s Hospital Boston, we have responded to the most pressing community health needs locally through the development of a community-based asthma initiative; our Fitness in the City program, which provides support to 11 Boston community health centers working to promote better nutrition among young people; the Children’s Hospital Neighborhood Partnerships effort, which provides mental health services in Boston schools; and our Martha Eliot Health Center, which provides health services in Jamaica Plain, along with programming to address youth violence and other health issues. Additionally, as the world’s largest and most active pediatric research enterprise, Children’s Hospital Boston significantly subsidizes a great deal of research, contributing heavily to the future of health care treatments for children. 

To ensure Children’s Hospital Boston, along with children’s hospitals across the country, has the ability to continue serving the community, their tax-exempt status must be maintained. 

• Any effort to alter requirements for tax-exempt status must include a community benefit definition that goes beyond a narrow charity care threshold.  Specifically, the definition should consider the impact of Medicaid losses, subsidies in research and training, and funding and resources directed to community health programming. 

Increasing Children’s Access to Health Insurance

While Congress is focused on expanding coverage, reform needs to ensure access to care.  Access requires appropriate benefits, a sufficient workforce, and willing providers.   Moving forward, reform efforts focused on insurance coverage must:

• Ensure that lower income children do not lose the comprehensive coverage and cost sharing protections they have under Medicaid and CHIP today.
 Since children cannot enroll themselves, every child through age 21 must be automatically enrolled in insurance at birth.
• To prevent gaps in care due to loss of employer sponsored coverage or moves to another state, programs serving children should incorporate fallback coverage.
• Given the high number of eligible, but unenrolled children, efforts to streamline applications and simplify re-enrollment should continue.

Ensuring Appropriate Benefits Packages for Children

Building upon the strength of the current system, we must ensure that the benefits package offered will be sufficient for the population being served.  Children’s special needs require benefits that support their development.  The Medicaid child-specific standard of Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) is a model medical necessity standard, which ensures that children receive not only preventative and primary care, but comprehensive coverage for serious conditions.

It is concerning that many proposals have focused on Medicare or the Federal Employee Health Benefit Plan (FEHBP), plans which do not include a standard of care that is appropriate for children.  Medicare is a program designed for older Americans.  Services that are either not offered or limited in FEHBP that are covered by EPSDT include developmental assessments, physical/speech therapies, and hearing services.  To be meaningful for children, reform must ensure that:

• Medicaid, connector plans, and any public plan should provide EPSDT services to children.
• Medicaid limits on cost sharing for lower-income children and children with special health care needs should continue.

Strengthening the Pediatric Health Care Workforce

Without an adequate supply of providers, insurance coverage and benefits are meaningless.  Unlike adult medicine, where primary care shortages are most pronounced, the most pressing workforce needs in pediatrics are found in specialties.  The shortage of pediatric specialists runs nearly across all fields with the top three shortages being neurologists, endocrinologists, and gastroenterologists.  Young physicians choosing to enter a pediatric specialty face many disincentives.  For example, they must train an additional 2-3 years, and will earn only a portion of the comparable salary of their adult counterpart.  To address these shortages, reform efforts must:

• Provide scholarships, loan forgiveness, and increased physician reimbursement under Medicaid to incentivize more physicians choosing pediatric specialties.
• Increase the number of GME slots to expand the overall size of the workforce. 
• Reallocate vacant pediatric residency slots within pediatrics.

Developing Fair Provider Reimbursement Policies

Medicaid and CHIP have been successful providing coverage to millions of children, but have fallen short on ensuring access.  Studies show that Medicaid pays physicians and hospitals well below the cost of care.  With 30% of our patients enrolled in Medicaid programs, the impact of inadequate payment policies on Children’s Hospital Boston is significant. 

In FY2008, Massachusetts’ established Medicaid rate resulted in a loss of over $20 million to Children’s Hospital Boston.  In FY2009, we believe that cuts to the state’s rates will result in an additional loss of $15 million.  The result would mean the hospital is reimbursed at a rate of 69 percent of the cost for these Medicaid patients.  This is exacerbated by even steeper losses from the Medicaid patients we serve from neighboring states.  In the face of state budget crises across the nation, federal reform can translate into access if:

• Medicare reimbursement rates serve as a floor for Medicaid

We thank you for your attention to these issues look forward to working with you to ensure that health care reform not only translates into access to care, but it works for children.


James Mandell, MD
Chief Executive Officer

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