The Nationwide Shortage of
Subspecialty Pediatricians

One state’s initiatives to create a better pediatric health care program
will be used as a federal model to overcome the shortages.


A North Carolina statewide program connecting primary care physicians to pediatric specialists will hopefully be a means to end the shortage of pediatric subspecialists in the United States. The program, Improving Pediatric Access through Collaborative Care (IMPACC), has been touted by two US governmental agencies as a national model to improve child and adolescent access to pediatric subspecialists who treat complex and chronic conditions including diabetes.

The Department of Health and Human Services and the Health Resources and Services Administration’s Maternal and Child Health Bureau, along with the Federal Expert Work Group, have chosen IMPACC as the sole national pilot program for its unique formula for collaboration between primary care physicians, pediatric subspecialists, payer organizations and patients. IMPACC was launched on August 17 with the goal of providing children with chronic and complex diseases — a number totaling 300,000 in North Carolina alone — with improved quality of life and reduced hospital admissions.

“It is not unknown to people in pediatrics, but it is a little less known to the general public that a lot of children across the country have . . . complex or chronic diseases and need subspecialty care,” said Alan D. Stiles, MD, during a teleconference hosted by the University of North Carolina (UNC), Chapel Hill, explaining that examples of chronic or complex disease include diabetes, cancer, asthma, cerebral palsy and sickle cell disease. Dr. Stiles is chair of the department of pediatrics at UNC, Chapel Hill and principal investigator for the IMPACC program.

There are a limited number of pediatric subspecialists. For example, in the United States, only 989 pediatric endocrinologists are in practice. This shortage, also seen in the areas of pediatric nephrologists, neurologists, rheumatologists and behavioral pediatric specialists, makes patient access difficult. Oftentimes, patients are required to drive long distances to visit the correct pediatric subspecialists.

“The shortage of pediatric subspecialists is a national crisis that will not be solved by any single change,” said Dr. Stiles, one of the physicians leading the development of IMPACC. Dr. Stiles worked with other pediatric specialists from UNC, Chapel Hill, North Carolina Children’s Hospital and North Carolina Medicaid. “About 2 years ago, we began a process discussing these issues … to see if there was a means to address the shortage … and our inability to either recruit or retain this group in the state along with opening the access for children who needed that type of care. Out of that was born IMPACC.”

Essentially, IMPACC is a coordinated care model linking pediatric subspecialists from medical centers with primary care physicians through two networks, the Community Care of North Carolina and Accesscare (see above). The IMPACC model was first tested as a pilot study in children with type 1 diabetes. Patients were monitored for 3 months and received care from a primary care physician and endocrinologist. All patients were enrolled at the Children’s Hospital or UNC, Chapel Hill and had severe and poorly controlled type 1 diabetes.

IMPACC utilizes a case management approach to care: Simply stated, case managers are available at both the primary care and medical center locations. These case managers are the liaisons between the two facilities and should be in close contact with the other health care provider team. For the pilot program, type 1 diabetes patients from across North Carolina were assigned a case manager from UNC, Chapel Hill who communicated with a primary care/community health case manager.

At the end of the study, the investigators noted a 15% decline in HbA1c levels. Improved adherence to treatments through the IMPACC program was the determined reason for improved HbA1c levels in all patients. Other outcomes included better diabetes control, a long-term improvement in quality of life for both children and their families, a reduction in the number of hospital/ER visits, cut down the amount of travel time to see a health care provider and improved attendance during the school year.

“Much of the work was done by the local case managers in the primary care setting by impacting things like schools, the ability to help patients manage their diabetes, home situations and seeing that medications were available,” said Dr. Stiles. “This suggests that this combined approach really has the potential to have a significant impact on how the outcome of the patients will evolve over a longer period of time.”

Another designation of the IMPACC program is telephone consultation between the primary care physician and subspecialist. Although telephone communication is a frequent form of communication for most practitioners, this formal method allows both parties to be reimbursed for the time spent on the telephone.

“This should facilitate the communication of needs of these children,” said Dr. Stiles. “[It will also] see that the management plans will be carried out in continuity.”

A secondary goal of IMPACC is to reduce the cost of care borne by the Medicaid system. In North Carolina, approximately 1.5 million people receive health care services through Medicaid, said Steve Wegner, MD, JD, president of Accesscare (Morrisville, NC) during the teleconference. Accesscare delivers health care to some patients serviced by North Carolina Medicaid. This Accesscare model is one portion of the IMPACC program, and IMPACC will save Medicaid at least 1%, or $5 million, in hospital costs each year. According to Dr. Wegner, the savings could reach over 10%. This, however, is not the most important issue. It is the quality of care that children needing pediatric subspecialists receive. “If these children can stay in school and not have to go to a hospital to get treatment that could be done in their community, they gain a great deal,” Dr. Wegner said.

IMPACC is funded by Duke Endowment, North Carolina Foundation for Advanced Health Care Programs, North Carolina Area Health Education Centers Program, North Carolina Division of Medical Assistance and Centers for Education and Research in Therapeutics. Several other medical centers are also participating in IMPACC. They include Wake Forest University, East Carolina University, Duke University, Carolinas Medical Center and Mission-St. Joseph Medical Center. The IMPACC model will hopefully help rejuvenate the lack of access to pediatric subspecialists seen nationwide.

IMPACC media briefing [teleconference]. Sponsored by the University of North Carolina School of Medicine. August 15, 2006. Available at: www.pcipr.com/newsroom/60815IMPACC.htm.
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