NEPHROLOGY. Chair s Letter. For Upcoming Newsletters NEWSLETTER THE SECTION ON. Fall 2013

THE SECTION ON NEPHROLOGY Fall 2013 NEWSLETTER Chair’s Letter Fellows and recent graduates of fellowship programs are the future of pediatric nephr...
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THE SECTION ON

NEPHROLOGY Fall 2013

NEWSLETTER

Chair’s Letter Fellows and recent graduates of fellowship programs are the future of pediatric nephrology. Yet, the AAP Section of Nephrology Executive Committee tends to be filled with more “experienced” (older) pediatric nephrologists. While somewhat the nature of many organizations, this deprives us of unique perspectives and skill sets. We have taken a number of steps to remedy this situation, including our recent bylaw change that creates a position for a pediatric nephrology fellow on the SONp Executive Committee. On July 1st, Nicole Christin, MD, a second year fellow at the Ann & Robert H. Lurie Children’s Hospital in Chicago, began serving a two year term as a member of the SONp Executive Committee. Nicole has already provided great ideas and a wonderful perspective. She will join us at our annual Executive Committee meeting at the ASN in Atlanta. We have also been targeting younger members of the Section for other roles, attempting to avoid the general tendency to look toward our own contemporaries. I also hope that some of our younger section members will volunteer to run for a position on the AAP Section of Nephrology Executive Committee (http://www.aap.org/en-us/about-the-aap/ INSIDE THIS EDITION Committees-Councils-Sections/Section-onNephrology/Documents/Callfornominations.doc). Chair’s Letter ......................................................... 1 For Upcoming Newsletters .................................... 1 I am delighted to inform you that the AAP has recently SONp Leadership Roster ....................................... 2 secured funding from the Friends of Children Fund to Federal Affairs Update: – Drug Shortages............... 2 develop an EQIPP course on hypertension. This course, AAP Supports Efforts Expanding which will cost approximately $111,000 to develop, will Medicare Coverage provide a mechanism for doing quality improvement of Immunosuppressive Therapy ............................. 3 work centered on hypertension. There will be separate 2014 Call for Nominations – modules for subspecialists (i.e., pediatric nephrologists Section on Nephrology and cardiologists) and general pediatricians. This course Executive Committee Positions .............................. 3 will fulfill MOC part IV, and also provide CME. I also Have you Checked-Out believe it will significantly improve the care of children. the SONp Website Lately? ..................................... 3 The course is being developed under the leadership of The Business of Pediatric Nephrology: Joseph Flynn and Don Batisky, with a team that includes Coding for Outpatient Nephrology Visits .......... 4-6 AAP Section of Nephrology members David Kershaw, Welcome New SONp Committee Member............. 6 Kevin Meyers and Dan Feig. Voiding Control and Enuresis in Children .......... 6-9 Continued on Page 2 Quality Connections Newsletter ............................ 9 Coverage of Supplements and Medical Nutritionals for Pediatric Nephrology Patients .................. 10-11 We welcome your input and encourage you to submit Pediatric Nephrology Workforce Survey ............... 11 ideas or information by email to Larry Greenbaum, Welcome to our New SONp Members ................ 12 MD, PhD at [email protected] or Suzanne Volunteers Needed .............................................. 13 Kirkwood at [email protected] for future issues of Upcoming Meetings ........................................... 13 the newsletter.

For Upcoming Newsletters

• Statements and opinions expressed in this publication are those of the authors and not necessarily those of the American Academy of Pediatrics. ©Copyright 2013 American Academy of Pediatrics Section on Nephrology

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Chair’s Letter Continued from Page 1 As usual, let me conclude by encouraging you to become more involved in the AAP. The AAP Section on Nephrology Executive Committee welcomes volunteers. There are many opportunities to get involved in creating CME or speaking at AAP conferences. While these activities take time, they are quite fulfilling. Write to me if you are interested! Larry Greenbaum, MD, PhD Chair, Section of Nephrology Executive Committee [email protected]

Federal Affairs Update –Drug Shortages The AAP continues to receive regular reports about drug and vaccine shortages. AAP Washington and Elk Grove Village staff are in regular communication with the Food and Drug Administration (FDA) to alert them about these shortages. At every opportunity the AAP urges the FDA to not only address the immediate shortage but also to find a long-term solution to drug shortages. The FDA drug shortages site can be accessed at: http://www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm

The Section on Nephrology Executive Committee Chairperson: Larry Greenbaum, MD, PhD, FAAP Executive Committee: Manju Chandra, MD, FAAP Nicole Christin, M.D. Frederick Kaskel, MD, PhD, FAAP Teri Jo Mauch, MD, PhD, FAAP William Primack, MD, FAAP Douglas Silverstein, MD, FAAP Immediate Past-Chair: John Foreman, MD Nominations Subcommittee: Katherine Dell, MD, FAAP John Foreman, MD, FAAP Tej Mattoo, MD, FAAP Barnett Award Subcommittee Juan C. Kupferman, MD, MPH, FAAP Steve Alexander, MD, FAAP Eileen Ellis, MD, FAAP Staff Suzanne Kirkwood, MS Manager, Section on Nephrology Mark A. Krajecki Journal Production Specialist

In response to a provision that was included in the 2012 Food and Drug Administration Safety and Innovation Act (FDASIA), the FDA formed an internal task force to develop and implement a strategic plan for enhancing the FDA’s response to preventing and mitigating drug shortages. As the task force moves forward on a strategic plan, they requested public comment from stakeholders interested in the prevention and mitigation of both drug and biologic product shortages. In March, the AAP Washington Office coordinated with more than 2 dozen AAP Committees, Councils and Sections to submit comments to the FDA on behalf of the AAP. Shortages in parenteral nutrition components such as sodium and potassium phosphate have been particularly acute. AAP is working with the Section on Perinatal Pediatrics, the Children’s Hospital Association, March of Dimes, and others to put pressure on Capitol Hill to urge FDA to find short- and long-term solutions to the shortage of these and other life-sustaining medicines. Reporting a Drug Shortage Pediatricians are encouraged to report drug shortages directly to FDA. To report a shortage of a drug product by email, please use [email protected] or to make a report by phone, please call (888) INFOFDA or (888) 463-6332. To report a shortage of a biological product (including blood, vaccines, tissue, allergenics) by e-mail, please use [email protected] or call (301) 827-4239. Pediatricians may also wish to report a shortage to American Society of Health-System Pharmacists (ASHP) at: http://www.ashp.org/shortages. ASHP maintains an up-to-date website with detailed information about ongoing and past shortages, alternative therapies, and information about when products are expected to be available.

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AAP Supports Efforts Expanding Medicare Coverage of Immunosuppressive Therapy The Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2013 legislation recognizes the extraordinary financial burden of renal disease in children and adolescents and amends Medicare to allow for the extension of coverage of immunosuppressive drugs for kidney transplant patients. Currently, those who qualify for Medicare based on end-stage renal disease are only covered for their first 36 months of costly immunosuppressive therapy after a transplant. The AAP recently sent letters supporting both the House and Senate bills seeking to extend this coverage beyond 36 months. These communications can be viewed at: h t t p : / / w w w. a a p . o r g / e n - u s / a b o u t - t h e - a a p / C o m m i t t e e s - C o u n c i l s - S e c t i o n s / S e c t i o n - o n Nephrology/Documents/ImmunosuppressiveBill_Senate.pdf and http://www.aap.org/en-us/about-theaap/Committees-Councils-Sections/Section-on-Nephrology/Documents/ImmunosuppressiveBill_House.pdf

2014 Call for Nominations – Section on Nephrology Executive Committee Member Positions The Nominations Committee for the Section on Nephrology seeks nominees to run for election to the Section on Nephrology Executive Committee. There are two positions available. The successful candidate will serve a three-year term beginning November 1, 2014. The Section Nominations Committee will review the nominees and select the candidates for the ballot. The election will take place in March 2014. It is important that the nominations committee receive a brief biographical sketch for each nominee (no more than 250 words) to review in addition to the nomination form. Submission of this form does not guarantee inclusion on the ballot. You may nominate yourself. However, if you would like to nominate a member to be considered for candidacy, please: 1. Talk to the member to ensure they are interested in the position; that they are a member of the AAP and also the Section on Nephrology (If you are a Section member you can view the list of current SONp members on the website at: www.aap.org/nephrology Click on the “About the Section” tab on the left; AAP ID and login required); 2. Access and complete the form at: http://www.aap.org/en-us/about-the-aap/Committees-CouncilsSections/Section-on-Nephrology/Documents/Callfornominations.doc 3. Email the completed form and a brief biographical sketch of the nominee (no more than 250 words) to [email protected] by November 15, 2013. CVs cannot be accepted.

Have you Checked-Out the SONp Website Lately? The SONp website (www.aap.org/nephrology) has recently received a face-lift and has a new look and feel that is consistent with the other Academy Committee, Councils and Sections. Most importantly it offers easier access to SONp information and other professional resources for members. Among the changes are: • Information for pediatricians interested in exploring a career in pediatric nephrology • Resources for fellows in training • Information for pediatricians participating in maintenance of certification • Links to AAP advocacy initiatives at the international, national and local levels Thank you to Drs. Rick Kaskel and Larry Greenbaum for their assistance in revising the website. We would appreciate your feedback as well as suggestions regarding a resources and links that you find helpful. Please contact Suzanne Kirkwood at [email protected]

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The Business of Pediatric Nephrology: Coding for outpatient nephrology visits By William Primack, MD, FAAP It is essential to code properly to ensure appropriate reimbursement, RVU credit, and compliance with CMS rules, especially for Medicare patients. Proper coding for outpatient visits is based upon the effort required as reflected in documentation. There are 3 types of outpatient visits each with its own code and RVU value’s (see Table 1). Consultation codes require a statement that the patient has been referred to you for evaluation and recommendations concerning a specific problem. If the referral is to assume care rather than to render advice, then it is a new patient visit rather than a consultation. Medicare no longer recognizes the difference between consultation and new patient codes for reimbursement, but many private insurers and Medicaid programs still do. A new patient is a patient who has not been seen by you or someone in your specialty group in the past 3 years. All other patients are considered established patients. What is the difference between various follow-up visit levels? • Level 1— primarily a nursing visit. Minimal or no physician contact • Level 2 — care of a simple, straightforward problem usually impacting only one system. Rarely used in nephrology. A general pediatric example might be a patient with conjunctivitis or a simple joint sprain. • Level 3 — a patient with a problem involving more than one system but of relatively low complexity. Few nephrology visits are level 3. An example might be follow-up of a teenager with well controlled hypertension. A general pediatric example might be a child with strep throat. • Level 4 — the most commonly used nephrology code. This involves a more complex illness, a detailed history or exam and moderate complexity decision making. Nephrology examples would be a child with relapsed nephrotic syndrome, SLE in remission, or a post renal transplant patient. • Level 5 — a complex illness similar to level 4 with comprehensive documentation in history or exam and decision making of high complexity or severity. Examples would be a frequently relapsing nephrotic patient where you are considering use of an additional immunosuppressive, a patient with SLE with whom you are discussing use of Cytoxan, or a patient with CKD4 or 5 with whom you are discussing (and documenting) decisions about dialysis and/or transplantation. Table 2 gives an outline of the criteria and documentation necessary for each level of coding.

Table 1 RVU VALUES New Patient

Consult

Established Patient

CPT Code

9920X

9924X

9921X

Level 1

0.48

0.64

0.18

Level 2

0.93

1.34

0.48

Level 3

1.42

1.88

0.97

Level 4

2.43

3.02

1.50

Level 5

3.17

3.77

2.11 Continued on Page 5

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The Business of Pediatric Nephrology . . . Continued from Page 4 Table 2

The next installment of the newsletter will review the criteria for coding new visits and consultations.

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Welcome New SONp Committee Member Dr. Nicole Christin is our new Executive Committee fellow liaison. Nicole was born in Miami, FL where she obtained her BS degree in Psychobiology and her MD degree from The University of Miami. She then moved to The Windy City where she completed her Pediatrics Residency at Ann & Robert H. Lurie Children’s Hospital of Chicago. Nicole is now a second year Pediatric Nephrology Fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago. Nicole is currently a member of the AAP, ASPN and ASN. She was inducted into Phi Beta Kappa her junior year of college and inducted into Alpha Omega Alpha during her third year of medical school. During her fourth year of medical school she served as President of AOA. Nicole has a passion for teaching and educating others. During her years as a Pediatric Resident she was a Facilitator for the Teaching Selective at Northwestern Medical School. This course was a requirement for all fourth year medical students and strengthened the students’ communication and feedback skills. Currently she holds regular Kidney case based teaching sessions with the third year medical students rotating though the Pediatrics Service and is part of Kidney Day, an orientation program for new nurses at her hospital.

Voiding Control and Enuresis in Children By Manju Chandra, MD, FAAP, Chief, Division of Pediatric Nephrology, Winthrop University Hospital, Professor of Clinical Pediatrics, Stony Brook University School of Medicine The human urinary bladder is entrusted with two major functions: storage of urine without leakage and efficient emptying at an appropriate time and place. During infancy, the bladder empties reflexively when it fills to functional capacity. An infant cannot inhibit or initiate voiding at will. A series of maturational processes, hormonal, neural, and structural, result in attainment of the ability to stay dry initially in the day and then at night by age 2.5 years, in at least 50% of toddlers. The steps in maturation of voiding control include: 1. Increase in bladder capacity 2. Perception of bladder fullness 3. Ability to initiate voiding at less than full capacity 4. Ability to inhibit a bladder contraction despite a full bladder 5. Ability to control the pelvic floor muscles Maturational delays and pathological alterations in the processes of voiding control can result in persistence of an infantile pattern of voiding. Nighttime and daytime wetting often reflects maturational delay in a child, and should be viewed the same way as other delayed milestones. Involuntarily wetting during sleep (nocturnal enuresis) is seen in about 15% of 5 year olds and 5% of 10 year olds. Some children never achieve steady dry nights (primary enuresis) while others start bedwetting at night after staying dry for at least 6 months (secondary enuresis). In children, daytime voiding symptoms of urinary frequency, urgency, and some urine leakage before reaching the toilet (the latter also termed urge incontinence) are usually caused by an overactive bladder: a bladder prone to reflex contractions that are not inhibited by the brain. The response to sudden bladder contractions varies in different children and at different times. It may include a mad rush to the toilet, total urge incontinence, or tightening of the pelvic floor muscles in order to abort the bladder contraction, postpone voiding and minimizes urine leakage. Giggle incontinence and stress incontinence in children are often a result of overactive bladder. Nocturnal enuresis results when the bladder fills to its functional capacity with urine, but the child fails to awaken in response to the stimulus from the full bladder. This causes the bladder to contract reflexively and empty during sleep. Continued on Page 7

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Voiding Control and Enuresis in Children Continued from Page 6 Therefore, nocturnal enuresis reflects interplay between bladder capacity, nocturnal urine volume and impaired sleep arousal. Increased nocturnal urine volume may result from inadequate nocturnal surge in antidiuretic hormone secretion, obstructed breathing or solute diuresis. The cause of impaired sleep arousal is unclear, but may reflect a dysfunction of the brainstem or autonomic nervous system. Low bladder capacity most commonly results from an overactive bladder. Some children with nocturnal enuresis can hold urine comfortably for several hours during the day (monosymptomatic or uncomplicated enuresis) while others also manifest daytime symptoms from an overactive bladder (non monosymptomatic enuresis). A careful history and physical examination will generally identify whether the wetting is due to maturational delay or from a structural problem in the urinary tract or nervous system. It is important to establish the general health and development of the child, and assess if any psychosocial and learning problems are present. The history should establish the frequency and pattern of voluntary and involuntary voiding during the day and night, and whether the child experiences uriweak or interrupted urinary stream, strains to void, or has difficulty in arousal from sleep. Other relevant factors include the child’s bowel emptying habits, the amount of fluid consumed during the day and just prior to going to sleep, whether there is a problem with obstructed breathing, the response to previous treatments and a family history of bed wetting and overactive bladder. Daytime voiding symptoms from an overactive bladder coexist with bedwetting in at least 50% of affected boys and 75% of girls. The parents of 45% of children with daytime urinary urgency and urge incontinence fail to bring these symptoms to the physician’s attention because they incorrectly ascribe them to the “child’s laziness” and “waiting until the last minute.” Physicians need to ask their patients about it directly, and be sensitive to signs of overactive bladder and urinary incontinence such as urinary urgency, erythema of the perineum, wet underpants and the odor of stagnant urine. The index of suspicion for undisclosed daytime voiding problems is higher in children with enuresis who manifest the following: secondary onset of enuresis, wetting more than once at night, easy arousal from sleep, spontaneous awakening to void, stool withholding, psychosocial and learning problems, and urinary tract infections. Urinalysis is needed to screen for large urine volume from a urinary concentration defect or diabetes A mellitus. If the specific gravity of a random urine specimen is not > 1.015, it should be rechecked in a first-morning urine specimen obtained after withholding fluids for about 10 -12 hours. In most children, bedwetting will be cured spontaneously during the process of maturation. However, an estimated 1-2% of untreated children will continue to have bedwetting as adults. Most physicians will treat bedwetting if it persists beyond a mental age of 5 years, but treatment may start earlier if it is associated with daytime symptoms of overactive bladder. Although monosymptomatic enuresis does not pose a medical risk for a child, children who regularly use pelvic tightening maneuvers to obstruct urine flow in response to the urge to void are at risk for recurrent urinary tract infections, perpetuation of primary vesico-ureteral reflux, development of secondary vesico-ureteral reflux, renal damage, as well as stool retention. The treatment of monosymptomatic enuresis should be directed at the predominant underlying problem e.g. increased night-time urine production, small bladder capacity or difficulty in arousal from sleep. The motivational and behavioral approach includes education of the child and family regarding the causes of enuresis, removal of guilt, fluid restriction 4 hours prior to sleep, a bedtime resolution to stay dry, keeping a diary of wet and dry nights, and rewards to encourage the child’s efforts. The best results are obtained when these techniques are combined with a bedwetting alarm and/or the administration of appropriate drugs to increase bladder capacity, decrease urine production at night and promote arousal from sleep. Appropriate use of a bed wetting alarm is quite effective in achieving a lasting remission. It should be noted that a difficult to arouse child may not awaken to the noise of the bedwetting alarm; therefore, a caregiver should awaken Continued on Page 8

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Voiding Control and Enuresis in Children Continued from Page 7 when the alarm goes off and take the child to the toilet. Many parents discontinue using the bedwetting alarm because it goes off “after” the child has wet or because of continued wetting. The child, however, may have shown improvement in bladder capacity and sleep arousal in the form of reduced wetness per episode and occurrence of wetting later in sleep. Desmopressin (DDAVP) given by mouth or as a nasal spray prior to sleep works by reducing nocturnal urine production. The success rate on the night of use is about 33%. DDAVP is more likely to be effective in those who have normal daytime bladder capacity, produce large amount of urine at night (assessed by weighing the diapers), wet only once at night and have a positive family history of monosymptomatic enuresis. Fluid restriction 4 hours prior to bed time is mandatory to prevent dilutional hyponatremia induced headaches and seizures. DDAVP is quite useful for sleepovers but has a low rate of long term cure. Anticholinergic drugs such as oxybutynin and tolterodine both of which prevent bladder spasms, are useful in children with low nocturnal bladder capacity. Such children give a history of wetting small volumes more than once at night and low bladder capacity during the day, which can be evaluated by asking how long the child can comfortably hold urine during the day and measurement of voided volume at maximum capacity. Imipramine may be effective in children with difficult sleep arousal who have normal daytime bladder capacity. It is typically a second line agent for children whose parents do not want to be bothered with use of the bedwetting alarm. As with all drugs, the risks and benefits of imipramine should be discussed with the family especially the risk of cardiac arrhythmia with over dosage or in those with familial predisposition for cardiac conduction defects. The family is advised about the necessity to keep the drug out of the reach of young children. A combination of drugs or use of a drug in combination with an alarm may be needed to achieve permanent remission of enuresis. To decrease the chance of a relapse, therapy should be continued until the child has no episodes of nocturnal enuresis for at least four weeks. Cure of bedwetting generally results in improved self-image and confidence. The treatment of a child whose bedwetting is associated with an overactive bladder is directed at preventing bladder spasms and the resultant pelvic floor tightening maneuvers. Using a behavioral approach, the child is instructed to voluntarily void at set intervals (e.g. every 2 hours) before the bladder can fill to capacity. The goal is to train the bladder to respond to the brain’s commands rather than contracting reflexively when full. The child is encouraged to keep a voiding pattern chart and should receive positive feedback and encouragement for his/her efforts and results. The voiding interval is gradually increased until the child can comfortably hold urine for 3.5-4 hours. Anticholinergic drugs are extremely useful adjuncts to the behavioral treatment of overactive bladder. A significant number of children with overactive bladder also manifest constipation or stool withholding, which needs to be treated concurrently. This is accomplished with the use of high fiber foods, mild laxatives and gentle persuasion to pass stool daily at a convenient time and place to prevent subsequent stool withholding. Children should be advised about optimal posture during voiding and bowel emptying. Humans have squatted to defecate for thousands of years. The present one-size-fits-all toilet, however, does not allow foot support for small children; they should be provided with foot stools to enable efficient rectal emptying. A history of overactive bladder and stool withholding should be repeatedly queried in children with enuresis who are treatment resistant. Normalizing the voiding and bowel emptying habits is important to achieving permanent resolution of bedwetting. Overactive bladder often coexists in children with other psychosocial and behavioral problems such as conduct disorder, attention deficit hyperactivity disorder, social anxiety and sibling rivalry. The child’s voiding problems may also elicit a punitive response from the parents. Addressing these issues will help the child to focus better on overcoming the day and nighttime wetting problems. Continued on Page 9

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Voiding Control and Enuresis in Children Continued from Page 8 As a general rule, the rate of response of the child to treatment of daytime overactive bladder and bedwetting will reflect the level of the child’s motivation and effort as well as the amount of parental encouragement and support the child receives. REFERENCES 1. Neveus T, Eggert P, Evans J, et al. Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document from the International Children’s Continence Society. J Urol 2010; 183:441-447 2. Chandra M: Enuresis and Voiding Dysfunction. Current Pediatric Therapy: Vol 18. Publ – Saunders Elsevier, Eds- Burg, Ingelfinger, Polin, Gershon, pp 588-594, 2006. 3. Chandra M et al: Prevalence of diurnal voiding symptoms and difficult arousal from sleep in children with nocturnal enuresis. J Urol 172:311, 2004 [PMID:15201802] 4. Yeung CK et al: Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 90:302, 2002 [PMID:12133069] 5. Butler R, Heron J, Alspac Study Team: Exploring the differences between mono- and polysymptomatic nocturnal enuresis. Scand J Urol Nephrol 40:313, 2006 [PMID:16916773] 6. Shreeram S et al: Prevalence of enuresis and its association with attention-deficit/hyperactivity disorder among U.S. children: results from a nationally representative study. J Am Acad Child Adolesc Psychiatry 48:35, 2009 [PMID:19096296]

Quality Connections Newsletter The Summer 2013 issue of AAP Quality Connections is now available at: http://www2.aap.org/attachments/ Summer2013QCNewsletterjpsFinal.pdf AAP Quality Connections was launched by the Council on Quality Improvement and Patient Safety (COQIPS), formerly the Steering Committee on Quality Improvement and Management (SCOQIM), to communicate timely information and increase awareness of the importance of quality improvement. The newsletter also provides updates on current AAP quality improvement programs and projects. • • • • • • • •

Highlights from the 2013 Summer issue of AAP Quality Connections: Birth of COQIPS Where Do “Quality Docs” Come From? QuIIN Update QI Project on Genetics in Primary Care IHI the Open School in Academic Medicine Quality Measurement for Child Neurology COCIT Update

Please direct any questions to Cathleen Guch, MPH, Manager, Health Information Technology Education, Division of Quality, [email protected]

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Coverage of Supplements and Medical Nutritionals for Pediatric Nephrology Patients What’s the Issue? One of the Section on Nephrology (SONp) strategic planning goals is to address the lack of or inconsistent payment for special dietary foods and physician-prescribed supplements related to children with certain kidney disorders. An initial review of the policies of the four largest commercial insurers (Aetna, CIGNA, UnitedHealthcare and WellPoint) revealed coverage variations among health plans including limited or no benefits coverage for nutritional supplements including vitamins, minerals and specialized foods. This lack of uniform coverage is relevant for patients with many types of conditions including children with end stage renal disease, chronic kidney disease, Fanconi syndrome, renal tubular acidosis, hypophosphatemic rickets, cystinosis, and Dent disease. Treatment of these disorders may require such nutritional supplements as part of their diet. Carriers often do not cover these items unless mandated by state law. Academy Efforts: • A resolution was submitted for the 2012 AAP Annual Leadership Forum (ALF) for consideration. The resolution, “Mandated coverage of medically required nutritionals”, while not among the top 10 resolutions, was supported by the attendees. This resolution was sponsored by the SONp and supported by several other subspecialty groups. • The Academy recently published the revised, “Scope of Health Care Benefits for Children from Birth through Age 26” which includes a recommendation of coverage of “special diets, infant formulas, nutritional supplements, and delivery (feeding) devices for nutritional support and disease-specific metabolic needs. (http://pediatrics. aappublications.org/content/129/1/185.full.pdf) • During the 112th Congress, the AAP helped lead a health organizational letter supporting Essential Health Benefits for medical foods. • Also, while not passed, the AAP endorsed the Medical Foods Equity Act (S. 311) sponsored by Senator John Kerry. The AAP released a new report on essential health benefits (EHB) for children. The ACA requires health insurance plans in the private market and health insurance exchanges to offer 10 EHB categories of service beginning in 2014. http://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Documents/EssentialHealthBenefitsReport October2012.pdf The AAP Private Payer Advocacy Advisory Committee (PPAAC) was established to identify strategies to enhance access through improved payment and health care benefits coverage for children and to advise the AAP and its leadership on strategies to improve pediatrician’s economic and organizational position in the private marketplace. AAP private payer advocacy works with key groups within the Academy on strategies to address coverage issues and new payment models by private payers. Through the PPAAC, assistance and resources are available to help members and chapters in addressing private payer issues. AAP members can assist private payer advocacy by reporting payer issues through the AAP Hassle Factor Form. This resource is available on the AAP Member Center for members to report problems with payers. This information will help the AAP and chapter pediatric councils in identifying and prioritizing issues to address with carriers. To access the hassle factor form, go to http://www.aap.org/en-us/professional-resources/practice-support/ financing-and-payment/Pages/Hassle-Factor-Form-Concerns-with-Payers.aspx For additional information on AAP private payer advocacy, contact Lou Terranova, Senior Health Policy Analyst at [email protected] The Academy, through its Division of State Government Affairs, is working very closely with chapters so that the health marketplaces implemented in 2014 are broad based and include qualified health plans that cover the Essential Health Benefits (EHBs) of importance to children. The Academy is also working with chapters to ensure that pediatricians are represented in marketplace discussions at the state level. In 2014, 17 states and the District of Columbia will have their own state-based marketplaces, 26 states will have federally-facilitated marketplaces, and 7 states will have “partnership” marketplaces. The Academy will continue to advocate for the inclusion of supplements and dietary foods in health insurance plans. Continued on Page 11

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Coverage of Supplements and Medical Nutritionals . . . Continued from Page 10 How can you help? 1. Complete the hassle factor form and send it to the AAP when patients report noncoverage of physician prescribed nutritionals or supplements for a nephrology related condition. 2. If you have had experience advocating on behalf of patients for coverage of these items, please send a copy of the letter to [email protected] so that we may compile various resources for members. 3. Join and work with your state AAP chapter and to ensure inclusion in state governed benefit packages.

Pediatric Nephrology Workforce Survey In the late 1990s, under the auspices of The Future of Pediatric Education II (FOPE II) Project, the AAP conducted a “Survey of Sections”. At that time, surveys were developed and sent to the members of 17 AAP medical subspecialty and surgical specialty Sections. The results are available at http://www.aap.org/fope2. This information was groundbreaking for many subspecialties, and even today, the data generated as a result of those surveys remains some of the only existing data regarding subspecialty workforce issues. The Section on Nephrology did not participate in the survey at that time. In 2012, the AAP began a new survey initiative which is based on the FOPE II surveys completed over a decade ago. The Section on Nephrology in conjunction with the AAP Division on Pediatric Workforce and Medical Education Policy and the American Society of Pediatric Nephrology (ASPN) collaborated in the development of a pediatric nephrology workforce survey that was fielded this past spring. Thank you to all who participated in the survey so that an amazing 68% response rate was achieved! The physician work group that developed the survey and is now in the process of analyzing the data includes: • William Primack, MD, FAAP • Kevin Meyers, MD, FAAP • Larry Greenbaum, MD, FAAP A wealth of information has been collected through the survey that we hope will be important in future pediatric nephrology workforce planning and advocacy efforts. Two abstracts (http://www2.aap.org/attachments/ PedNephWSAfor2013ASN.pdf) were submitted for the American Society of Nephrology conference in November. An abstract that addresses the perceived pros and cons of a career in pediatric nephrology has been accepted for a poster presentation. Future activities will include submitting abstracts for the 2014 Pediatric Academic Societies meeting and the development of articles for possible publication. An overall summary of the results of the survey is being compiled.

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Welcome to our New SONp Members If you know of others who might be interested in joining the Academy and the Section please have them call 1-800433-9016 ext. 5885 or go to www.aap.org. The link entitled Member Benefits will take them to an application. Current Academy members may join the Section by accessing the online application (member ID and login required) at: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Pages/Council-Section-Membership.aspx AAP FELLOWS: Elizabeth Anyaegbu, MD, FAAP Corpus Christi, TX

Elizabeth Brown, MD, FAAP Dallas, TX

Ari Auron, MD, FAAP Clive, PA

Gangadarshini Chandramohan, MD, FAAP San Marino, CA

Tammy Brady, MD, MHS, FAAP Silver Spring, MD

Deborah Price Jones, MD, FAAP Nashville, TN

A special welcome to training fellows who were added to the Section. (As of July 1, 2012, Section dues for pediatric nephrology training fellows were eliminated.)

Oleh Akchurin, MD New York, NY

Elizabeth Hunt, MD Cambridge, MA

Watfa Al Dhaheri, MD Montreal, QC

Clare Lindner, MD Pittsburgh, PA

Prabesh Bajracharya, MD Farmington Hills, MI

Haendel Munoz, MD Houston, TX

Anke Banks, MD Calgary, AB

Shahid Nadeem, MD Atlanta, GA

Lauren Becton, MD New York, NY

Lieuko Nguyen, MD Castro Valley, CA

Frank W. Ayestaran Cassani, MD Atlanta, GA

Matthew O’Rourke, MD Cincinnati, OH

Sherman Chu, MD Shrewsbury, MA

Meghan Pearl, MD Los Angeles, CA

Stephanie Clark, MD Philadelphia, PA

Ari Pollack, MD Seattle, WA

Michael Freeman, MD Pittsburgh, PA

Weiwen Shih, MD Palo Alto, CA

Hossam Eldee Hassan, MD Hamden, CT

Tennille Webb, MD Wexford, PA

Fall 2013

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Volunteers Needed One of the goals of the Executive Committee is to increase its level of communication with and participation of Section members. As a result, we are currently looking for members who might be interested in serving to: • Contribute to the Section Newsletter or assist in identifying members and content for future newsletter articles. • Review existing or develop new articles directed at parents for the Academy’s parent website at http://www. healthychildren.org/English/Pages/default.aspx • Write an article for the Focus on Subspecialties column in AAP News regarding pediatric nephrology topics. Examples of past articles can be accessed at: http://www.aap.org/en-us/about-the-aap/Committees-CouncilsSections/Section-on-Nephrology/Pages/Newsletters.aspx • Participate in the Section Nominations Committee. The Committee is responsible for identifying candidates to serve on the Section on Nephrology Executive Committee and creating the election ballot. Individuals serve for two years or two election cycles. • Participate on the Henry Barnett Awards Committee. Individuals serve a two year term. Please contact Suzanne Kirkwood at [email protected] if you are interested in serving in any of the above positions or have additional questions.

Upcoming Meetings AAP National Conference & Exhibition October 26-29, 2013 Orlando, FL http://www.aapexperience.org/ Kidney Week 2013 November 5-10, 2013 Atlanta, GA http://asn-online.org/education/kidneyweek/ Renal Physicians Association Annual Meeting March 20-23. 2014 Baltimore, MD http://www.renalmd.org/Introduction/ National Kidney Foundation – 2014 Clinical Meetings April 22-26, 2014 Las Vegas, NV http://www.kidney.org/news/meetings/clinical/ Pediatric Academic Societies Meeting May 3-6, 2014 Vancouver, Canada http://www.pas-meeting.org/ European Renal Association-European Dialysis and Transplant Association – 51st Congress May 31-June 3, 2014 Amersterdam, Netherlands http://www.era-edta2014.org/ 47th Annual Scientific Meeting of the European Society of Pediatric Nephrology September 18 – 20, 2014 Porto, Portugal http://espn2014.org/

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THE SECTION ON

NEPHROLOGY Fall 2013

Fall 2013