Are we losing a generation of pediatric subspecialists?

A review conducted by UC Davis pediatricians and published in the Journal of Perinatology, raises the alarm on a potential crisis in the pediatric subspecialty workforce. Medicaid pays for about 41% of births in the U.S., but under-reimbursement is having a profound impact on hospital incomes and, along with that, salaries for pediatric endocrinologists, nephrologists, neurologists, intensive care physicians and other subspecialists.

“There is a significant concern about the future of this country’s pediatric workforce,” said Satyan Lakshminrusimha, chair of the UC Davis Department of Pediatrics. Lakshminrusimha, a neonatologist, is medical director of UC Davis Children's Hospital and first author of the review. “Not many medical students are going into pediatrics, and not many residents are becoming pediatric subspecialists.”

The study echoes a recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), which raised concerns about patient access to subspecialists. Lakshminrusimha and his co-authors are worried these trends will drive long-term shortages that could compromise care.

Low salaries deter young physicians

Low Medicaid reimbursement generates a cascade of bad outcomes, including low subspecialty salaries, which pushes medical students and residents into specialties that offer better compensation. Lakshminrusimha notes that many students pursue medicine because they are inspired by a gifted pediatrician. However, the relatively low salaries, combined with high debt loads from medical school, can make pediatrics unappealing.

“Pediatricians’ salaries are much lower compared to other specialties,” Lakshminrusimha said. “Salaries for subspecialists in adolescent medicine, infectious diseases and other areas are even lower. We are asking people to spend four years in medical school, three years in a pediatric residency and another three years in a pediatric fellowship, only to make less than a family practitioner. In some cases, physicians who pursue an additional fellowship see their salary potential go down.”

As a result, hundreds of pediatric residencies go unfilled, which gets magnified in subspecialities. The nationwide review found that 40% of the residency slots in pediatric genetics, infectious diseases, nephrology, endocrinology and developmental-behavioral are vacant.

“We have an epidemic of pediatric obesity and high autism numbers, and we are concerned that we will not have enough providers to take care of these patients,” Lakshminrusimha said. “Even now, we are starting to see long waiting lists for patients, and recruiting faculty in these specialties has become quite challenging.”

On a larger level, low Medicaid reimbursement can badly impact hospital sustainability. At UC Davis Children's Hospital, as many as 60% of pediatric inpatients receive Medi-Cal, California’s Medicaid program. Low reimbursement affects the Department of Pediatrics and the hospital as a whole.

Medicaid reform could provide incentives

With so many children covered by Medicaid, the authors strongly urge reform. One idea is to put Medicaid rates on par with Medicare reimbursement. Another proposal suggests changing how pediatric subspecialists are reimbursed for specific procedures.

“An adult gastroenterologist, for example, can do 15 routine colonoscopies in a day,” Lakshminrusimha said. “But in pediatrics, every child undergoing a colonoscopy has major disease, making it a far more delicate procedure that takes two or three times longer. What we really need is some kind of policy change where pediatric specialists get an incentive for seeing the patient. Ultimately, we must find creative ways to solve this problem, or we simply won’t have enough pediatric subspecialists to treat our children.”

Co-authors include David A. Lubarsky, UC Davis Health; Rhae Ana Gamber, Vizient Inc.; and Sherin U. Devaskar, UCLA.