Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
During the past two decades, the adult population in the United States has become not only far more heavy but far more expensive when it comes to providing healthcare coverage, according to a new Congressional Budget Office (CBO) issue brief.
From 1987 to 2007, the percentage of adults who were overweight or obese increased from 44% to 63%, with almost two-thirds of the adult population now falling into one of those categories. The share of obese adults rose particularly rapidly, more than doubling from 13% to 28%.
That sharp increase in the percentage of adults who are overweight or obese pose "an important public health challenge," the CBO analysts note. Those adults are more likely to develop serious illnesses, including coronary heart disease, diabetes, and hypertension—a trend that also affects healthcare spending.
This corresponding healthcare spending per adult (in 2009 dollars) rose almost 80% from 1987 to 2007, from about $2,560 to $4,550—led in part by the "development and diffusion" of new medical technology, more extensive insurance coverage, the aging of the population, and rising inflation-adjusted prices for healthcare services. That spending grew among all weight categories, but in the data that CBO analyzed, the rate of growth was much more rapid among the obese population.
For example, between 1987 and 2007, per capita spending grew by 65% for normal-weight adults and by 61% for overweight adults. However, it grew much faster for obese adults—by 111%. As a result, obese adults had per capita spending that was far higher when compared to spending for normal-weight adults in 2007 than it was in 1987: that difference rose from 8% in 1987 to 38% 20 years later.
CBO looked at several future scenarios to determine the impace of weight on the healthcare system. For one scenario, no future changes would be anticipated in the distribution of adults by body weight—the prevalence of obesity would remain at the 2007 rate of 28%. In this situation, per capita spending on healthcare for adults would rise by 65%—from $4,550 in 2007 to $7,500 in 2020—"largely as a result of rapidly increasing healthcare spending for all adults regardless of weight," the CBO analysts say.
In another alternative scenario, CBO assumed a rising prevalence of obesity, matching recent trends. In that scenario, the prevalence of obesity would rise to 37% by 2020, with per capita spending increasing to $7,760—about 3% higher than spending in the first scenario.
CBO also assesses the impact of a reversal in recent trends—with obesity dropping. In that scenario, the prevalence of obesity among adults would decline to 20% by 2020. Per capita spending would increase to $7,230 about 4% lower than spending in the first scenario.
Since lower rates of obesity are associated with better health and lower healthcare spending per capita, devising policies that would reduce the fraction of the population that is obese is a consideration. However, the challenges are significant.
In a sternly worded message to health insurers, Health and Human Services Secretary Kathleen Sebelius said last week that the federal government will not "stand idly by as insurers blame their premium hikes and increased profits" on changes related to the new healthcare reform legislation.
With the announcement this month by several insurers that they were sharply raising their 2011 premiums in light of anticipated costs under new healthcare reform measures, Sebelius said in a letter to Karen Ignagni, president and CEO of America’s Health Insurance Plans that HHS will be keeping track of those insurers. Those plans—or others that have "a record of unjustified rate increases"—could be excluded from health insurance exchanges when they begin operating in 2014, she said.
HHS will issue a regulation this fall that will "require state or federal review of all potentially unreasonable rate increases filed by health insurers, with the justification for increases posted publicly for consumers and employers," Sebelius added.
The HHS letter comes on the heels earlier in the day of a release of a study from Centers for Medicare and Medicaid Services economists that healthcare cost increases may be slightly higher under healthcare reform provisions. Earlier estimates from sources such as the Urban Institute and Mercer, Sebelius said, have indicated that the impact of reform measures "will be no more than 1% to 2%."
"The trends in health costs, independent of the legislation, have slowed. Employers’ premiums for family coverage increased by only 3% in 2010—a significant drop from previous years," she said.
Ignagni says that health insurance premiums were increasing for next year because of "soaring prices for medical services, the impact of younger and healthier people dropping their insurance during the weak economy, and additional benefits required under the new law."
The new healthcare reform law now requires that health insurance coverage include a wide range of new benefits "beyond what many families and small businesses previously purchased," Ignagni said. "It's a basic law of economics that additional benefits incur additional costs, and the impact on premiums depends on the type and amount of coverage policyholders had before."
She added that health plans, while incorporating new benefits, will be trying to keep “healthcare coverage as affordable as possible for families and employers.”
Any premium increases should be "moderated by out?of?pocket savings resulting from the law," Sebelius says. These savings include a reduction in the "hidden tax" on insured Americans that subsidizes care for the uninsured, she added.
By making sure insurance covers those most at risk, less uncompensated care will be anticipated and therefore "the amount of cost shifting to those who have coverage today will be reduced by up to $1 billion in 2013," Sebelius says.
The U.S. Court of Appeals for the D.C. Circuit approved a request Thursday from the Justice Department to lift a temporary injunction, issued Aug. 23 by a lower court, that had blocked the funding of stem cell research.
The three-judge appeals panel, though, stated that this was not a final decision: "The purpose of this administrative stay is to give the court sufficient opportunity to consider the merits of the emergency motion for stay and should not be construed in any way as a ruling on the merits of that motion." Opponents of stem cell funding have until next week (Sept. 14) to file a response; the government must submit its response by Sept. 20.
In a lawsuit filed by two researchers working on alternatives to the cells, U.S. District Judge Royce Lamberth ruled last month that the current funding had violated the Dickey Wicker Amendment, a law that that prohibits federal money from being used for research involving the destruction of human embryos. On Tuesday, Lamberth had declined a request to lift the stay.
In response to the District Court order, the National Institutes of Health had suspended consideration of any new grants related to stem cell research. The researchers who had received prior funding could continue; however, their grants could not be renewed as they came up for routine review while the injunction was in effect.
Tucked into the healthcare reform legislation passed this year is a provision that calls for state grants to create initiatives to encourage Medicaid beneficiaries to adopt healthy ways of living to prevent chronic disease. But before any state—and while we're at it, any employer, insurer, or health system—moves ahead with an incentive plan, they may want to look at the West Virginia example cited by the American College of Physicians (ACP)in a paper on the use of patient incentives to promote personal responsibility for health.
ACP uses the West Virginia Medicaid program--one of the earlier controversial programs to use incentives—to highlight some of the problems that can befall incentive programs, even when they're started with the best of intentions.
As ACP notes in its recommendations, programs should support a patient's role in achieving positive health outcomes. Moving down the path of penalizing individuals who fail to meet goals (such as smoking or weight loss) by withholding or reducing benefits or increasing health insurance premiums won't work in the long run, it said.
In 2007, the West Virginia Medicaid program implemented a new benefit plan that was designed to improve health by promoting personal responsibility. The Medicaid would be divided into a behavior-based two-tiered benefit structure: the basic plan and the enhanced plan.
The basic plan offered fewer services than the enhanced plan, which provided unlimited prescriptions and transportation, and programs such as weight management, smoking cessation, diabetes education, nutritional counseling, and substance abuse treatment.
To get into the enhanced plan, patients and their physicians would develop a "health improvement plan" in which patient would be required to agree to a number of conditions such as: medication adherence, attendance at recommended educational programs, keeping scheduled appointments or notifying the office to cancel, timeliness for appointments to their medical home, visiting the medical home when sick, and using the hospital emergency room only for true emergencies.
Sounds great—initially. But as it turns out, the program's goals fell short. A preliminary evaluation revealed that two years after implementation, only 10% of eligible adults and 13% of eligible children even were enrolled in the enhanced benefits plan. Other patients reported limited knowledge of the program—before and after enrolling—while clinicians reportedly felt confused about the paperwork and benefit structure.
"Incentive programs should not discriminate against a class or category of people," says Virginia Hood, MBBS, a co-author of the paper. "Age, gender, race, ethnicity, and socioeconomic status should be carefully considered in designing, implementing, and interpreting results of social and behavioral interventions."
To encourage a dialogue, ACP has compiled a list of recommendations on what should be considered when implementing incentive plans, including:
Incentives to encourage healthy behaviors should be appropriate for the target population. Specifically, the incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control.
Incentives to promote behavior change should be consistent with the elements of patient-centered care. This means the incentive structure should support appropriate patient autonomy and participation in decision making—including the right to refuse treatment—without fear of punishment.
Incentives should support "honest, open and fair interactions" among patients, healthcare professionals, healthcare entities and payers. In particular, health plans should not interfere with "the ability of patients to communicate freely with physicians and other health care clinicians," the paper states.
Incentives to promote behavior change should be consistent with the elements of patient-centered care. This means that the incentive structure should support "appropriate patient autonomy and participation in decision making—including the right to refuse treatment”—without worrying about punishment, ACP says.
The road to a healthier future is paved with great intentions. Let's just make sure we're not using punishment, confusion, or other disincentives to push us off that course.
Healthcare spending nationwide appears not to be slowing down as much as initially anticipated since healthcare reform legislation was approved this past spring, according to figures released Thursday the Centers for Medicare & Medicaid Services.
Currently, spending is expected to reach about $4.6 trillion by 2019—growing at an average annual rate of 6.3% over the next decade, they state in a new report in Health Affairs. However, they had projected an annual growth rate of 6.1% in February—one month before the reform legislation was signed into law.
In addition, healthcare is now expected to account for 19.6% of the gross domestic product (GDP) by 2019, which is 0.3% higher than projections made in February. This means that close to $1 out of every $5 will be used to purchase healthcare, they added.
"While the estimated net impact of the Affordable Care Act and other legislative and regulatory care changes are moderate, the underlying effect of these changes on coverage and financing are more pronounced," says CMS economist Andrea Sisko, one of the study coauthors.
For example, the economists are projecting an increase in spending by a greater number of insured individuals. This is largely offset, though, by slower projected Medicare spending growth, as well as lowered Medicaid prices paid to providers to render services to newly insured Medicaid recipients, Sisko added.
In 2014—the year in which many ACA expansions of coverage take place—faster spending growth is predicted for private health insurance spending, as well as for Medicaid and the Children's Health Insurance Program, Sisko says.
Specifically, this expanded coverage is expected to increase by 9.2%—which is higher than the 6.6% rate proposed in February, Sisko said. In addition, public spending is projected to increase by 9.7% in 2014, while private spending is expected to increase by 8.6%. However, with more people insured in 2014, out-of-pocket spending could decline by 1.1%—instead of rising 6.4% as projected earlier in the year.
For 2010, healthcare spending is projected to reach $2.6 trillion, accounting for 17.5% of the GDP, up 0.2 percentage point from pre-reform estimates. The economists attribute this growth in large part to postponement of cuts to Medicare physician payments and legislative changes to COBRA premium subsidies.
By 2011, though, public and private health spending is expected to grow more slowly if reductions in the Medicare physician payment rate go into effect—especially the 23% reduction that starts in December 2010 and the expiration of COBRA premium subsidies begins.
Among other CMS projections are:
From 2015-2019, national health expenditures are projected to grow at an average annual rate of 6.7%, slightly less than the pre-reform projection of 6.8%. This reduction in Medicare spending growth is projected to be 1.4% lower than pre-reform estimates.
The new administrative function for health reform at HHS is projected to cost $2.4 billion between 2010-2019. Health insurance exchanges are projected to cost $37.7 billion.
Nearly 93% of people will be insured by 2019—a level nearly 10% higher than the share of the population that was expected to be insured without the passage of healthcare reform.
Enrollment in Medicaid and the Children's Health Insurance Program is projected to increase by 21.8 million in 2014 to 85.2 million people.
In response to a petition filed last week by Public Citizen and others, OSHA said it will examine the need for regulations that would limit the work hours of resident physicians, according Labor Department Assistant Secretary, David Michaels.
"We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents," Michaels said.
He also said that the relationship of "long hours, worker fatigue and safety is a concern beyond medical residents, since there is extensive evidence linking fatigue with operator error”. In its investigation of the root causes of the BP Texas City oil refinery explosion in 2005—in which 15 workers were killed and approximately 170 injured—the Chemical Safety Board "identified worker fatigue and long work hours as a likely contributing factor to the explosion."
"It is clear that long work hours can lead to tragic mistakes, endangering workers, patients, and the public," he said. "Hospitals and medical training programs are not exempt from ensuring that their employees' health and safety are protected."
In its petition, Public Citizen cited recommendations made by the Institute of Medicine in its 2009 Report on Resident Duty Hours. They included:
A limit of 80 hours of work each week, without averaging.
A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians.
At least one 24-hour period of time off work per week and one 48-hour period of time off work per month for a total of five days off work per month, without averaging.
And in-hospital on-call frequency no more than once every three nights, no averaging.
These recommendations are "necessary for protecting the safety of resident physicians and subspecialty resident physicians," according to the petition submitted by Public Citizen, the Committee of Interns and Residents/SEIU Healthcare, and the American Medical Students Association.
"Their implementation would also have the secondary benefit of resulting in a safer, better standard of care for patients nationwide," the petition added.
Recently released data from the Census Bureau shows that the number of uninsured children in the U.S. decreased from 8.1 million in 2007 to 7.3 million in 2008—the lowest since 1987. But efforts still need to be used to reach as many as 65% of (about 4.7 million) of those uninsured children who are eligible for coverage through Medicaid or the Children's Health Insurance Program (CHIP), said participants at a Department of Health and Human Services briefing on enrolling children in the programs.
Among uninsured children, 39% are concentrated in "a relatively small number of populous states"—California, Texas, and Florida, said Genevieve Kenney, a senior health fellow at the Urban Institute and co-author of the report on Medicaid and CHIP that appears on Health Affairs online. A total of 61% of those uninsured children (2.9 million) are concentrated in 10 states.
Overall, in 2008, the national participation rate in either Medicaid or CHIP was 82%, said Kenney. "This level of participation is high relative to what's typically found in other means-tested government programs—which is probably due to the many efforts that states...have made over the last decade to improve enrollment and retention in both Medicaid and CHIP."
"The share of children without health insurance in America is lower than it's ever been before, and that's very good news—that children don't bear the brunt of this economic downturn," said HHS Secretary Kathleen Sebelius at the briefing. "But our work has only begun."
But despite advances that states have made, millions of uninsured children remain who qualify for coverage but are not enrolled. "I'm challenging everyone, from my state and federal counterparts, to local governments and community-based organizations, to health centers and school districts, to faith-based groups and Indian tribes, to take this conversation about children?s coverage to the next level—to find and enroll those five million kids," Sebelius said.
As part of the CHIP Reauthorization Act passed last year and the Affordable Care Act, "we are investing $120 million in innovative state and local outreach efforts," Sebelius added. "We don't have to write any new laws to do this, and we don't have to pass any bills through Congress. We just need to find the young people and get them enrolled."
The study confirms that the states "have been doing a good job" enrolling children," Sebelius said. But the current participation rates have been found to vary greatly across states—from lows of 55.4% in Nevada and 66.2% in Utah to highs of 95.4% and 95.2% respectively in the District of Columbia and Massachusetts, Also, Hawaii, Maine, Massachusetts, Vermont, and the District of Columbia had participation rates of 91% or higher.
While Arkansas, Kentucky, Louisiana, Michigan, New York, and West Virginia had rates of 88% to 90%, a total of 13 states had participation rates that fell below 80%: Alaska, Arizona, Colorado, Idaho, Florida, Montana, Nevada, North Dakota, Oregon, South Carolina, Texas, Utah, and Wyoming.
The data "will help us to focus our efforts and our grant funding where they are most needed," Sebelius said. "We now have a much better sense of where most uninsured children live, and which communities may need more help."
Among other facts listed in the Health Affairs article are:
The vast majority of uninsured children (88.2 %) come from families where at least one parent is working.
71% of uninsured children in the U.S. have family incomes below 200% of the Federal Poverty Level ($36,620 for a family of three in 2009).
Among uninsured children living with a parent, nearly 60% live in two?parent households
A majority of uninsured children (88.2%) come from families where at least one parent is working.
71% of uninsured children in the U.S. have family incomes below 200% of the Federal Poverty Level (or $36,620 for a family of three in 2009).
The HIPAA compliance world awaits two major final rules per HITECH—the breach notification final rule and the rule that covers modifications to the privacy, security and enforcement rules.
But that’s no reason to sit idle.
Here are a few tips for HIPAA privacy and security officers as they await the final rules:
1. Focus on business associates (BAs) and contracts with them. CEs need to be certain that they have identified all of their BAs and that they are bound by BA agreements, says John C. Parmigiani, MS, BES, president of John C. Parmigiani & Associates, LLC, in Ellicott City, MD.
HITECH made BAs subject to compliance with the HIPAA Security Rule and the use and disclosure provisions of the HIPAA Privacy Rule.
The proposed rule makes it clear that HIPAA and HITECH apply to BAs and require them to comply with most of the same rules as CEs. If they haven’t done so already, CEs must review their BA agreements to ensure that they include appropriate language, says Phyllis A. Patrick, MBA, FACHE, CHC, cofounder and managing director of AP Health Care Compliance Group, which has offices in Pittsburgh and Purchase, NY.
CEs must ensure that their BA agreements emphasize the need for BAs to be up to date with the latest HITECH requirements pertaining to the HIPAA privacy and security rules and enforcement compliance/outcomes for noncompliance, says Parmigiani.
BAs need to make sure BA contracts are in place for all of their CE customers. HITECH made BAs equally responsible for entering in to a BA contract with CE customers. BAs should ensure the contracts include language that puts the CE on notice that the BA is required to inform the CE if the CE appears to be violating the HIPAA privacy and security rules. If the CEs don’t comply with the rules within a reasonable length of time, BAs are required to report CE violations that to OCR.
BA contracts should address the role of BAs in a privacy breach in more specific language. Address questions such as breach notification requirements and financial responsibility for responding to a breach, says Patrick. “All that needs to be spelled out,” she says.
HITECH addressed the need for BA compliance. The proposed rule would extend compliance requirements to BA subcontractors by expanding the definition of BA to include them.
CEs are required to include language in BA contracts that mandate downstream compliance with the HIPAA privacy and security rules by BAs’ subcontractors with access to the CE’s PHI, says Parmigiani. Be sure BA contracts require BAs to impose compliance requirements on subcontractors.
2. Focus on working relationships with BAs. Sometimes CEs sign contracts with their BAs and their interaction ends there. “You have agreements with people who have never even met each other,” says Patrick. CEs need to know they can count on their BAs if a security breach occurs, she says. That’s when you want to be able to pick up the phone to communicate with your BA and know you can rely on people there. There must be a good working relationship between the BA, the department head who works most closely with that BA, and the HIPAA privacy and security officer.
This is especially true for BAs who work with a large quantity of PHI. This can include vendors involved in IT, electronic data interchange, third-party billing, health plans, and pharmacy benefits.
3. Create an informal forum to bring together privacy and security officers with other staff members concerned with patient safety. The proposed rule would revise the privacy rule’s definition of healthcare operations to include a reference to patient safety activities. Patient Safety Organizations, which receive reports of patient safety events or concerns from providers and analyze events, will be considered BAs of covered healthcare providers.
Patrick says patient privacy should be considered a piece of the regulatory pie, along with safety and quality. At many healthcare organizations, privacy and security programs and patient safety programs operate in silos, she says. The proposed rule will make it more important for HIPAA privacy and security officers to reach out to staff members involved in quality and patient safety at their organizations.
A group consisting of representatives of those programs met monthly and provided a forum to discuss common issues at a hospital where Patrick once worked. Members provided updates so everyone knew what was happening in other programs. Organizations that do this may also consider involving representatives from the patient relations department.
This type of forum is a good place to address risk assessments together, Patrick says. The meetings can be confidential with no minutes or record necessary.
“This is a way of breaking down silos. It helps everyone in the long run,” she says. “I would urge every organization to start a forum, even if you start with two or three people. It will pay dividends.”
Correspondent Joanne Finnegan contributed to this report.
Healthcare programs in Cincinnati and Detroit have been awarded $30 million in grants for three years as the final two pilot locations for the Department of Health and Human Services' (HHS) new Beacon Community Program. The program is using health information technology to help tackle leading health problems in communities across the country.
The lessons learned from these pilot programs will be incorporated into nationwide strategies for electronic health record adoption, according to HHS. The program also will allow HHS to look for new ways to share lessons learned by funded communities and—working with local and national healthcare foundations—to develop support networks for other communities that want to employ similar approaches.
The latest awardees—Greater Cincinnati HealthBridge and Southeastern Michigan Health Association in Detroit—are joining 15 other projects selected in May for the Beacon Community Cooperative Agreement Program. The other communities, which earlier received $220 million in Beacon program funding, include: Tulsa, OK; Stoneville, MS; Brewer, ME; Danville, PA; Salt Lake City, UT; Indianapolis; Spokane, WA; New Orleans, LA; Rochester, MI; Providence, RI; Grand Junction, CO; Concord, NC; San Diego, CA; Hilo, HI, and Buffalo, NY.
"Although we could only select two additional Beacon communities, we are incredibly impressed by the creativity and focus exhibited by communities over the course of this competition," said David Blumenthal, MD, the national coordinator for Health Information Technology.
"Local leadership is an essential ingredient to improving health care. The Beacon Community application process provides strong evidence that communities throughout the country are mobilizing for positive change, using health IT as a critical foundation for improving health care," he added.
The Greater Cincinnati HealthBridge, will received $13.8 million over three years. HealthBridge will be serving a 16?county area spanning three states surrounding greater Cincinnati. Under the Beacon program, HealthBridge and its partners will use its advanced health information exchange program to develop new quality improvement and care coordination initiatives focusing on patients with pediatric asthma, adult diabetes, and encouraging smoking cessation.
Physicians and other providers will receive more timely and accurate information about when their patients experience a medical complication or are hospitalized. Also, they will have new support from care managers to use this information effectively to intervene early and assist patients in managing their health and avoiding further complications.
The HealthBridge program also is aiming to provide better clinical information and IT "decision support" tools for physicians, health systems, federally qualified health centers, and critical access hospitals. As part of the Beacon program, this health IT community collaboration also will also provide patients and their families with timely access to data and tools to make informed decisions and manage their own healthcare.
The Southeastern Michigan Health Association, which was awarded $16.2 million over three years, will use health IT tools and strategies with its partners to prevent—and better manage diabetes—which impacts a large percentage of residents in the Detroit area.
This community collaboration will be leveraging existing and new technologies across healthcare settings to improve the availability of patient information at the point of care—regardless of where the patient is in the health system. The community also will provide practical support to physician practices to help clinicians, nurses, and others make the best use of electronic health data.
The city’s clinical community will have the ability to track clinical outcomes with the goal of making long?term, sustainable improvements in the quality and efficiency of diabetes care in Detroit, Hamtramck, Highland Park, Dearborn, and Dearborn Heights.
The Beacon program is one of several new programs created by the Health Information Technology Economic and Clinical Health (HITECH) Act as part of the Recovery Act last year.
Department of Health and Human Services Secretary Kathleen Sebelius announced Wednesday that three sets of grants and cooperative agreements totaling nearly $17 million have been made available for patient-centered outcomes research—or what also is referred to as comparative effectiveness research.
The three-year funds—made available under the American Recovery and Reinvestment Act of 2009 through the Health Resources and Services Administration (HRSA)—is to be used to establish a network of PCOR centers, enable PCOR in pediatric emergency medicine, and supply building space for community-based providers to engage in this type of research.
The funds will be used by providers "to bring patient-centered research knowledge into everyday clinical decision-making for the diverse and vulnerable populations that HRSA serves, and that are often under-represented in this kind of research," says HRSA Administrator Mary Wakefield.
Five cooperative agreement awards will go to organizations in four states to create the Community Health Applied Research Network (CHARN). This project will be used to demonstrate how safety net providers and academic institutions can partner together to create an effective infrastructure that supports patient-centered outcomes research.
The CHARN consists of a Central Data Management Coordinating Center, based at the Kaiser Foundation Hospitals' Center for Health Research in Portland, OR, and four networks selected as research "nodes" in California, Illinois, Massachusetts, and Oregon. The nodes are part of a consortia of safety net providers located in 17 states.
This network will focus on providing an opportunity to examine patient-centered outcomes research among diverse populations and patient subgroups that have often been excluded or not adequately represented in similar studies.
Three of the four research nodes will focus on patient-centered outcomes research related to the delivery of primary care, while the fourth—in Boston—will focus specifically on research that is relevant to the care and treatment of individuals with HIV/AIDS.
Another grant totaling $3.5 million will be made to the American Academy of Pediatrics at Elk Grove Village, IL, to support development of an electronic health record sub-network within the Pediatric Research Network in the Office Setting—the nation?s largest pediatric primary care research network. The results from this work will be used to help structure guidelines and policies in pediatric practice.