San Francisco Sunday, October 3rd

Say what you will, the signage was nothing if not comprehensive.

Sunday always begins with the traditional Division Breakfast, a chance to get to know other pediatricians from your part of the country while standing in line for burritos. This exercise involves the dual challenge of making it to the meeting room by 7:00 AM after your first big night out and not spilling eggs down your shirt while leaning over to shake hands. I succeeded at one of these.

Opening by Francis Rushton, Chair, Division IV

This year we skipped the tradition of passing the microphone around to introduce ourselves, as we only had an hour and, being from the South, many of us talk slow. Dr. Rushton then passed the floor to our tireless legislative lobbyists.

Erin Wallace, Federal Affairs

• Health Reform was very successful for us, at least to begin
• Two major implementations occurred September 23
• All Bright Futures provisions get paid for in new plans
• Children may remain on parents' plans up to age 26
• No exclusions for preexisting conditions in new health plans or ones that change substantially
• Over the last six months we've been working on the details of writing the law
• Many components have been authorized but not appropriated
• There is much advocacy left to do to get appropriations, enroll children
• The Federal Affairs website is full of useful details

Dan Walters, Federal Affairs

• Now federal provisions are going to states, where there're is often little money to implement health reform
• Many states have commissions to implement health reform, and these offer opportunities for advocacy
• Many states have filed suits to prevent implementation of health reform
• Some insurers have withdrawn child only health plans, but some states are stepping in to keep this from happening. California has done this already.
• States are asking insurers to justify prohibitive rates when present
• States are deciding how to run health insurance exchanges, high risk pools. They may defer this job to the Federal government if they choose
• By 2014 Medicaid will be extended to adults, payment to physicians will increase to 100% of Medicare
• Insurance plans that are grandfathered will not be held to these requirements, and the definition of such plans is still being worked out.

Francis Rushton emphasizes that we all need to learn what an accountable care organization is. It's not clear whether they will be good or bad for us, but we need to stay involved as they are formed so we have a seat at the table.

Incoming President Marion Burton from South Carolina is recognized. Dave Tayloe is out visiting other divisions, but former AAP President Steve Edwards is here as well.

Multiple District IV members have been recognized with national awards.

Dr. Josh Honnecker of Kentucky is our representative to the chapter forum at the Annual Leadership Forum. He will present any resolutions we have to the AAP leadership. Submit by early November for consideration.

These proposals are how the grass roots membership impact AAP policy

Jackie Noonan speaks on behalf of Friends of Children, Chilren's future Fund. The AAP Is a moor source of philanthropy for children affected by disasters in places like Haiti and Pakistan

Jane Foy, District Vice Chair announces a new push on Vaccine Hesitancy

• The mental health toolkit is available, which Jane did tremendous work to create. She will be giving a workshop Tuesday morning on using it.
• The toolkit involves tools on getting paid for providing mental health care in the office

Jennifer Williams, outgoing residency coordinator introduces obesity campaign for residents

Melissa Hudgins talks about Young Physicians group, working on advocacy projects, reminds us to involve our younger partners in practice. Time management is a big focus for them.

Voter participation was low in this year's AAP election despite reaching out in multiple electronic media and electronic voting.

Chapter officers stand to introduce themselves

Herb Clegg stands to promote the PROS research network for practices. Now recruiting for a big teen smoking cessation study

Fill out your surveys on reimbursement, because that's the only way the AAP knows how to advocate for improved reimbursement for specific services we provide

Steve Edwards stands to remind us that the process of implementing health reform at the state level is a tremendous opportunity both for success and for failure now, and we need to be involved in how it's done.

Breakfast over, it's time to dash through the crowd in search of a good lecture. I knew whom I wanted to hear:

Extreme practice makeover

Herschel Lessen, MD

• Physician demographics a shifting to physicians who train fewer hours, do fewer things during their training.
• Costs have been shifted to patients, which increases the value of procedures, decreases the value of thinking.
• This means all primary care is a commodity. That means as far as the patient is concerned quality is level across all physicians, quality does not matter at all.
• Therefore competition is all about volume.
• 77% of patients in the US are covered by one of three managed care corporations.
• Success is no longer to be taken for granted, survival is as good as it gets
• To survive you have to get bigger, better.
• Many Practices are in need of an economic makeover
• Pediatric salaries are bimodal, most make very little, but a reasonable number make a whole lot. Who are those doctors?
• Best size is 11 to 25 physicians
• It is a huge problem that physicians don't think administration deserves the same level of reward as caring for patients
• We are the only medical specialty that sees making money as morally wrong
• Doing good and doing well are not mutually exclusive. This is hard for many pediatricians to embrace.
• Many pediatricians are very resistant to change, but you don't change, you die.
• Models: the Marathon Man practice. Working every day, all day, doing everything yourself. Burnout risk is high. Some join big practices then have no control.
• Problem: poor planning. No one taught us business skills. We lack knowledge of internal and external data. We never have a business plan.
• The health of your practice depends on your knowledge of your numbers.
• Another model: the Dwindling Practice. Providers keep leaving, numbers shrinking. These doctors were stuck in buildings they owned, so they could not move. They had lousy coding and insurance contracts. They saw too few patients a day. These practices had huge problems with change.
• Know what your revenue is, how many patients are actually in your practice, how many visits you have and how many visits the average patient makes. What is each patient worth? Average revenue divided by total number of patients. Know what payer gives you the most per patient seen.
• What is the cost per patient? Total overhead divided by number of patients. If a payer is giving you less than that number, renegotiate or drop them.
• Average revenue per visit should be a bit over $100. You may want to back out vaccine costs since they are now so high, both as income and as expense.
• Make sure you know what you are paying for everything. Negotiate everything.
• Know your personnel needs. Some staff make you a lot more money then they cost. Don't be afraid of overhead when that overhead makes you money.
• Develop a written budget!
• Then monitor the budget and keep track of how you're doing.
• Get an area map with zip codes, see how many children are in each zip code, how many come to your practice. Focus your marketing where there are lots of children and they don't yet come to your practice!
• How do you decide when to expand? You can add doctors to lighten your workload, but then you have to know if there are enough patients to fill those doctors' schedules.
• Get good advice, it's worth the money.
• You can go to an American College of Physician Executives course.
• Make a business plan! Look at productivity of providers, drop those who cannot make their salaries.
• Problem: poor structure. A small practice often lacks infrastructure. The idea is to keep the doctors doing what only they can do, offloading other jobs to less highly compensated people.
• Having a lot of partners is often not a good thing. Give the employed physicians a good deal in terms of lifestyle, pay them fairly but not like the partners who take the risk and share the burdens.
• For partners you need people with business skills who really want to be involved in management
• Problem: poor governance. You must have clear lines of governance. Consensus only works if you're very small. More effective to rule by executive committee. Worst is veto power by passive aggression where one partner undercuts what the others decide by not cooperating. This is the single most dangerous person in any practice. One person should know and control the schedule.
• Know what your practice culture is. What's important to you? Control? Lifestyle? Compensation? Embracing of change? How hard do you want to work?
• Don't try to control those things where someone else does them better than you. Trust the personnel who are good at their jobs.
• Define the partnership in a written, detailed agreement, and look at it every few years.
• You need buy in to the governance structure.
• Problem: poor efficiency. How many patients per provider per day do you need to see? What types of patients are seen by each physician during different seasons? Analyzing patient flow and wait time is critical.
• Monitor schedule, adjust work flow based on demand. The scheduling partner should know what kinds of patients different providers like to see. Must tweak schedule frequently based on demand.
• Doctors must be aware of their schedule and know how far behind they are. Need adequate staff and rooms to keep all the balls moving. Patients who need more prep time should arrive early soothe doctor is not waiting on them.
• Use handouts, follow up visits to get complex explanations done. Make sure nurses do everything they can do that the doctor doesn't have to.
• Use protocols for tests, like throat cultures.
• Problem: poor contracting. Read every contract every year. Find your lowest payer, then beat them up.
• Negotiate everything, but know what's important. Know your code frequency and fight for even small increases in the ones you use most.
• Code aggressively! At least 25% should be level four, probably more. Five percent should be level 5.
• Under coding is as bad as over coding.
• Do coding audits!
• Do as little as possible for free, such as writing letters and filling out forms.
• Make sure copays are payed at the time of service.
• Accept credit cards.
• Problem: poor customer service. The bar is so low that it's easy to outperform others.
• Everything about your practice speaks to the consumer.
• Seek good advice. A good administrator will pay off many times over. Rely on SOAPM.
• Have a health care attorney.
• Use a management consultant from time to time.

Next came plenary sessions. Unlike the first day convention staff did not block the doors once all the seats were taken. The first speaker was one of my favorite people in the AAP.

Molly Droge, MD

Department of State Government Affairs

American Health Care At A Crossroads: Implications of Health Reform to States and Opportunities For Advocacy

• Affordable Care Act
• States face a $547 billion shortfall in Medicaid for 2009-2012
• 37 states will elect governors this year
• Our priorities remain the same: coverage, benefits, access to care
• ACA should cover 32 million more Americans
• Preventive care will be based on AAP Bright Futures guidelines, cover all recommended vaccines, fund medical home demonstration programs
• By 2014 all citizens, resident aliens, and dependents must have qualifyingnhealth care coverage. 40 states are trying to restrict implementation of this mandate., and there are multiple lawsuits against this mandate.
• These obstructions are unlikely to do much, but the public perceives that implementation is not likely to happen.
• That said, each state will differ in how the law is implemented, and it's critical we remain involved in that process.
• High risk pool programs: states must decide whether to do their own or go in with the federal plan. North Carolina is going it alone.
• Medicaid eligibility expands to 133% of the poverty level
• CHIP and Medicaid enrollment for children must not change until 2019
• By 2014 web based Medicaid and CHIP enrollment is mandatory
• Health Insurance Exchanges will be rolled in over time starting with business involvement and then adding larger businesses.
• Tax credits will help small business owners provide health insurance for their employees
• The exchanges will simplify the process of comparing insurance plans.
• Rate increases will have to be approved by the states
• Insurers will have to spend at least 80% of their income on medical care, and if they don't they will have to reimburse the insured
• Grandfathered plans are those patients were already enrolled in as of March
• Consumer protection reforms went into effect 9/23/2010
• California now has the first health insurance exchange
• The affordable care act was a monumental victory for children, but we must now stay involved in order to help it succeed
• Look at the AAP Member Center online for more information and guides.

Dr. Richard Oken

The Primary Care Physician: An Endangered Species?

• Primary care is the first contact with patient and can manage a complex patient over time.
• We focus on prevention, long term relationships
• Now it's getting hard to find primary care doctors.
• Many new pediatricians do not want to work full time.
• Night call is not fun
• Phone calls are triaged
• We don't do hospital work now
• Now we do ADD, obesity, behavior management, vaccinations
• New doctors come out owing $150,000
• A quarter of new docs work part time
• Hours and fees have both fallen by 25%
• Hospital pediatricians make almost $30,000 a year than us
• Specialists make much, much more money
• CRNA will make more than a pediatrician
• There was a 7.6% drop in visits from 2009 to 2010
• Concierge care is not a viable model for most pediatricians
• Preventive care provides long term, not short term benefits so shareholders do not reward it
• The RVRBS system was generated by specialists and does not reward us
• No margin, no mission.
• Financial viability is critical to our survival
• New docs care about their families more than their jobs, we have to take that into account.
• Primary care as we knew it is a failed business model

Robert L. Hendren, DO
Are Imaging And Other Technologies Helpful In The Diagnosis Of Mental Disorders?

• Neurodevelopmental model is a promising concept for understanding brain development
• More and more disorders, liken substance abuse, fall within these definitions
• Currently history and physical exam remain our most important mental health diagnostic tools
• Can biomarkers help us diagnose and monitor these diseases?
• Can we identify mental disorders with imaging studies?
• The problems are not with brain mass but with connections
• Now image for funny head, regression, family history, abnormal neurological exam, new onset unexplained disorder.
• There are providers who charge families to do SPECT scans and show them, but this is still not valid as diagnostic tools
• The Amen Clinic is one group that does a lot of this, but the literature is very weak indeed
• QEEG is another modality that some are pushing, but again the data are not there to suggest neurofeedback would be effective
• Do genomics, proteomics, or other similar technologies tell us much? When we find a genetic disorder, then sometimes yes, but otherwise now.
• The preferred test with autism is a CGH array
• Fragile X testing may be useful. Also test when appropriate for Preader Willi, Angleman, Williams, Retts, velocardiofacial syndrome, PTEN. Often history and physical exam will eve this testing.
• Should we perform metabolic studies in autism? The yield is very low, and most of the disorders are caught with newborn testing.
• For autism consider CBC, Metabolic panel. Some think FMR1, high resolution cytogenetic testing.
• Think of lead and iron screening, thyroid
• When do you look for oxidative stress biomarkers? May look at b12, folate, vitamin d, glutione,CRP
• There are no norms for provoked urine heavy metal levels, no one knows how to interpret them

Dr. Marilyn Goske

Medical Radiation: Is there a problem?

• Yes, there is.
• CT scan settings are often not adjusted for the size of pediatric patients
• Utilization of radiologic studies has gone up dramatically without improving the outcomes for children
• With computer technology an over exposed study still looks good, in fact it looks better!
• We cannot really measure the dose of radiation, only estimate it
• The current index may underestimate doses by 300%
• We don't get feedback for years. The outcomes are decades in the future
• Children are more sensitive to radiation, and risk is cumulative
• Consumers are now demanding lower doses, better justification for studies
• High dose radiation causes immediate, deterministic effects
• Stochastic effects are delayed, due to long term exposure
• It remains controversial as to whether CT scans contribute to cancer, no one really knows, but it's wise to act cautiously.
• MR and ultrasound cause no ill effects
• CT scans cause by far the greatest radiation exposure compared even to fluoroscopy
• Image Gently campaign is a social marketing campaign to encourage behavior change locally

Dr. Terry Huang

The Complexity of Childhood Obesity

• Obesity is a global crisis, not just in the US
• Even in India and China we're seeing up to 10% of children overweight
• Overweight women have macrocosmic babies, and so pass on the problem in some ways
• Worst in US are Mexican-American boys, African-American girls
• This is a systemic problem, and individual self control is not enough
• Look at the UK Foresight Programme Report, it's awesome!
• Complex systems include individuals, institutions. They interact over time, they include feedback loops, they evolve and adapt over time. A small change in one part of the system may have a huge impact in another part of the system.
• Did our emphasis on low fat diets actually drive increased carbohydrate intake? In complex systems there are often unintended consequences
• You can tax sugar, but that only helps if you improve access to healthier options
• Behavior modification alone does not work unless the surrounding systems are also modified
• Interventions will need to involve agriculture, trade, urban design, education, government
• Working on using computer models to test ideas and look for unintended consequences
• Do your best for overweight patients, but know that societal and systemic change is really the key!

Lunch. Sushi. Latin Jazz in the park. Couples dance salsa on the sidewalk and children run under the trees as sunshine plays on the cool grass and a 72-degree breeze tousles your hair. Doesn't it just make you want to take a deep breath and go sit down in another dark conference room?

You Too Can Be A Breastfeeding Expert

Michelle Brenner, MD, IBCLC, FAAP

Joan Meek, MD, MS, FAAP

• www.aap.org/breastfeeding is one useful resource, the curriculum for residents is there
• www.bfmed.org is another data rich site
• Toxnet at the national library of medicine is a great resource for which medications are safe in lactation
• How do you deal with maternal-infant separation? Start with expressing milk as soon as possible. No amount is too small, and you should expect to express small amounts at first
• Ideally use hospital grade double electric pump. Pump 8-10 times a day, goal of 350-500 ml per day.
• Use warm soaks and breast massage prior to pumping. Use hands to get all the milk out.
• Milk left in the breast inhibits further milk production.
• The more milk you can remove the better the supply will be!
• Kangaroo care is important to help initiate breastfeeding after a separation from mom.
• Cup feeding is safe, can also use spoon or nursing supplementer. Syringe is best used with a little silastic tubing taped on the finger or taped to the side of the breast while baby sucks
• Nipple shields are gaining popularity, especially with moms with flat nipples ornwith low tone infants or those who don't suck well. Babies still need to suck with wide open mouths. Shields may also help transition from bottle back to breast.
• Breast pumps should not cause pain. Turn the suction down if it does! Don't stare at the pump, think about the baby!
• Hypotonic infants: any weakness of suck or abnormal mouth development may cause problems, but these babies may benefit even more from breast milk.
• Babies with poor coordination may do better at the breast than with bottle feeding.
• Use a good, firm hold like cross cradle helps these babies. Use hand expression to start milk flow. Mom should hold her breast like a taco, not a sandwich, for this position
• Using the hand to support the baby's face may help as well.
• There is a protocol for feeding the hypotonic infant at the American academy of breastfeeding medicine website
• Cleft lip and palate babies are great candidates for breastfeeding. Breast or finger may need to be used to close the lip defect.
• With palate defects it depends on the size of the defect. Holding baby upright can help keep milk flowing downward
• Breatfeeding multiples. Simultaneous nursing is ideal, but a big challenge.
• Milk volume should be fine. Remember wet nurses used to nurse 8 to 10 babies a day.
• Causes of nipple pain: incorrect positioning, suction trauma, infant anatomical issues, engorgement, milk bleb, Raynaud's, thrush, contact dermatitis
• Ankyloglossia decreases tongue length, may cause problems with breast feeding, alter normal tongue movement
• Affects 3-5% of newborns. Majority are asymptomatic, but about 25% may require clipping
• Moms complain of nipple pain, erosions.
• Infants may make clicking sounds while sucking, may be fussy, fatigued, sliding off breast, chewing on nipple.
• Tongue may appear normal but be restricted from the bottom or at the base
• Swipe your finger under the tongue. Resistance may indicate a problem.
• When problems arise with nursing keep the baby fed, protect the breast milk supply.
• The tongue should be covering the lower alveolar ridge during nursing
• Moderate exercise and reasonable weight loss are tolerable during breastfeeding.
• There is still not a good, evidence based product to improve breast milk production except for metoclopramide, but obviously this drug has some down sides.

Beth Vogt, MD

Blood Or Protein In The Urine, How much work up is necessary?

• Urine dipstick is semi quantitative, detects both heme and protein
• Heme is present in red cells but also in myoglobin
• Protein usually means albumin
• If you can do urine microscopy in your office that's best, since some elements will break down before the lab can get it.
• Bright Futures does NOT recommend any routine office urine screening and has not since 2007.
• Some school forms may require urinalysis, and every now and then you find something. In the future we will probably have a selective screening guideline for children at higher risk for kidney disease.
• Hematuria must include >5-10 RBC per high powered field as well as positive dipstick
• 4-6% of children will have hematuria on a single screen, fewer that 1% with repeat testing.
• Glomerular hematuria: blood cells get into the urine from the glomerulus.
• Include post-infectious GN, most often after strep throat
• Even after resolution microscopic hematuria will persist, often up to a year
• Chronic glomerulonephritis, most common IgA nephropathy.
• Keep chronic microscopic hematuria, then when they are sick they get gross hematuria,which resolves along with the illness
• Hereditary nephritis, most common Alport syndrome, associated with deafness
• Thin basement membrane disease is generally benign
• Extraglomerular hematuria, from outside the glomerulus
• Most common is hypercalciuria, which can lead to kidney stones
• Increased salt and protein in our diets has led to an increase in calcium excretion
• Kidney trauma may cause gross hematuria.
• Hydronephrosis, cystic kidney disease, tumors, sickle cell trait, nutcracker syndrome, and vascular malformations are other causes in this category
• Lower down there is cystitis, bladder tumors, bladder stones, trauma, STD's, urethrrhagia
• Also heavy exercise, menses
• Upper tract bleeding looks brown due to oxidation of the hemoglobin
• Protein is usually greater in higher sources of bleeding
• Evaluation of course starts with a good history
• Physical exam may include changes in weight, blood pressure, abdominal masses, edema, rashes
• Confirm dipstick two more times before getting all worried about hematuria
• Check urinalysis on parents as well. Obtain urine culture. Check urine calcium to creatinine ratio. Check kidney ultrasound.
• Kids rarely need cystoscopy
• Hematuria and protein together require more evaluation: CBC, c3, c4, ANA, ASO, BMP
• Protein: 1+ is normal if urine is concentrated. 2+ or greater is never normal
• Check spot urine protein to creatinine ratio. > 0.2 is abnormal.
• A 24 hour collection is the gold standard, but not all patients do this correctly
• 10% of kids age 8-15 will test positive initially, but only 1% on repeat testing
• Transient proteinuria is self limited, often due to illness, stress, dehydration
• Orthostatic proteinuria is the most common cause of a positive screen, levels less than 1 gram in 24 hours.
• Check a first morning urine and protein should go away, unless the child sleeps standing up.
• Fixed proteinuria is present day and night, consistent, does not go away. This indicates kidney disease.
• May be FSGS, polycystic kidneys, reflux nephropathy, others
• First step, if child is I'll then recheck when illness resolves
• If first morning urine is without protein you're done, but patient must void right before going to bed, get sample as soon as they wake up.

So word is in San Francisco they have this wharf for fishermen creatively named "Fisherman's Wharf." Apparently some people like to go down there and walk around, and they have food as well as tee shirts that say, creatively, "San Francisco." I got a chance to try this totally sour bread they call, you guessed it, sourdough. Follow me for more tips on tourism off the beaten path.

Oh, and one more thing. A lot of the tourists don't know this, but apparently there's a place there where they make chocolate. If you go at the right time they'll even sell you some.