Absent Adolescents: Solving the Problem of Continuity of Care Through the Teenage Years

“I want patients and their families to feel like they have a relationship with the office, and that idea is built into the design,” said Dr. Julia Pillsbury, who founded the practice in 1991. The practice has now grown to include two additional providers.

The practice has been carefully designed with both young children and adolescents in mind. Some exam rooms cater to teens, with adult-sized exam tables, and are absent of overly-childish themes. And, while caring for adolescents is an implicit part of every pediatric practice, Dr. Pillsbury chose, in planning every detail including the name of the practice, to give this at-risk patient population special attention. “We made the decision from the start to put ‘adolescent’ in the name so parents know their teenager is an important part of the practice.” One of the benefits of having a small, independent practice is the ability to make choices that will result in better clinical care for patients.

Each of these small decisions is part of a larger strategy to create a Patient-Centered Medical Home for the family, so that when children reach adolescence they continue to utilize their pediatrician for important preventive care. Dr. Pillsbury said that while it’s very rewarding to take care of someone from birth to college, it can be difficult to do so, with teens frequently underutilizing clinicians. Data shows that a drop-off for adolescent well visits begins at age 12, as the percentage of patients up-to-date decreases with each year they are active in the practice. Fewer than half of all 16 year olds have had a well visit in the last year.¹

With adolescents making up a whopping 20 percent of the population, getting them in for regular well visits is an opportunity for pediatric practices to improve both clinical care and their bottom line. While adolescent well checks are time-consuming and often not as well paid as other types of visits, they’re an important part of creating a Patient-Centered Medical Home and are often an opportunity to generate previously unrealized income.

The Battle of Convenience

In the past, part of the decline in well visits for adolescents and teens could be explained by a lack of insurance coverage. In 2008, one in seven adolescents ages 10 to 18 had no form of public or private health insurance, but with the advent of the Affordable Care Act, most people now have some form of health insurance, even though their deductible may be high.² That insurance usually includes coverage for preventive care, including at least one well-child visit per year.

But, the problem isn’t just that teens aren’t going in for well visits. It’s that if they are, they’re likely receiving “sports physicals” at either school-based health clinics or urgent care facilities and not from their pediatrician. “I’m not sure if it’s because of a lack of understanding, or if it’s encouraged by schools, but it seems to me that a lot of these kids are getting their exams at a school-based health clinic,” said Dr. Pillsbury. “Parents think that if their teen can get the same exam at school or an urgent care facility, they don’t need to bother making an appointment and bringing them to the pediatrician. It’s not convenient.” With no appointments needed at an urgent care facility, the temptation is strong for many busy parents to skip an in-depth well visit with their child’s pediatrician in favor of a five-minute physical.

In addition to battling the convenience of school-based clinics and urgent care, pediatricians also face the challenge of false-equivalency pricing comparisons for their services. Many adolescents and their parents believe that a sports physical is equivalent to a well-child exam, but this is far from the case. A sports physical is designed to clear an athlete for participation in sports and includes a physical examination and a brief discussion of the child’s medical history. A well exam includes developmental and immunization histories, long-term health concerns and risk factors, and advice for developing a healthy lifestyle. These are all things a pediatrician with a long history with the patient and family is uniquely qualified to provide, and a defining component of the kind of Patient-Centered Medical Home Dr. Pillsbury has intentionally provided for families in her practice.

“While a clinic may offer a ‘sports physical’ for $35 or $50, it may sound a lot cheaper than what I’m going to do it for, but it’s the same cost to parents if their insurance pays for a comprehensive exam they’ll get from their pediatrician,” she said. “Parents aren’t really aware of the kinds of developmental counseling we do.”

An At-Risk Population

While parents correctly believe that adolescents are a generally healthy population, they are also entering a critical period for mental, social, and emotional development. According to the National Center for Children in Poverty, approximately 20 percent of adolescents have a diagnosable mental health disorder, many of which first present during adolescence.³ Additionally, teens and adolescents are at an especially high risk for some of the most serious and costly health problems, such as alcohol and drug use, smoking, unintended pregnancy, accidents, suicide and sexually-transmitted disease.

The Bright Futures guidelines from the American Academy of Pediatrics recommend a well visit every year for healthy adolescents, while patients who show risk behaviors should be seen more frequently.⁴ Annual checkups are the perfect forum for addressing these adolescent health issues and pediatricians offer a broad range of preventive services for teens, including immunizations, screening for depression, vision problems, and scoliosis, as well as anticipatory guidance on nutrition, exercise, alcohol and drugs, sexual behavior, peer pressures, and injury prevention. And, with privacy becoming an important factor around age 12 when patients and their physicians can speak confidentially without parents present, healthcare professionals say teens are twice as likely to ask about important developmental topics during these checkups.⁵

Dr. Pillsbury said that, while she can’t be sure exactly what’s covered in a typical well visit at school-based health clinic: “If they’re offering a day when every freshman can come in and get a ‘sports physical,’ I would doubt they’re really doing a quality well visit.” In contrast, a well visit at Dr. Pillsbury’s practice generally takes between 25 and 30 minutes for an adolescent. “With these clustered exams at clinics, there’s a good chance they are only examining students physically and will only be referred back to their family physician if something is abnormal.”

In addition to being less comprehensive, a visit to a clinic for physicals may prevent a patient from receiving the much-needed well visit from their pediatrician due to insurance limitations on well-coverage. “With most insurances covering one annual well visit at 100 percent for adolescents, if urgent care facilities or school-based health clinics are billing these physicals to their insurance as a preventive medicine visit, that’s where these kids are really getting short-changed,” said Dr. Pillsbury.

“All the developmental counseling and risk prevention we do doesn’t happen during the ‘sports physical’ at an urgent care or school-based health center.” Additionally, pediatricians have a long-standing relationship with patients that can help detect problems that may not be evident to someone with less history. While most physical problems are discovered before adolescence, others are primarily spotted during the teenage years, such as scoliosis or developmental delays, and are best detected with a physician that knows the patient and has access to their full medical history.

“One of my sons had his growth spurt and then just stopped growing,” said Dr. Pillsbury. “That’s not a typical growth pattern. If you have a kid who has started their growth spurt and then peters out, that’s something we would be able to pick up on because we have all their growth patterns, whereas a school-based health clinic won’t have their full growth curve from the last 10, 12, or 15 years.”

How Do You Compete?

So how do pediatric practices compete with the convenience and perceived low cost of urgent care or school-based clinics?

“You have to have appointment times available outside of business hours,” said Dr. Pillsbury. The Center for Pediatric and Adolescence has extended hours from 7 a.m. until 6 p.m. and also has Saturday appointments available. “Those appointments from 4 to 6 fill up first, and they’re largely for well visits and ED followups–appointments that parents don’t want kids to miss school for.” There is an additional fee for appointments during these extended hours, which many parents are happy to pay in exchange for the convenience, and helps the practice cover the costs of the additional office hours.

The practice has also started not scheduling patients for chronic appointments until they’ve had their well visit, or blocking out additional time to do both appointments together. “We get a lot of kids that have ADD or asthma and they’ll be really good about coming for those visits. We try to get them scheduled for a well visit and the parents think, ‘I just don’t have the time for that,’” said Dr. Pillsbury. “Their child is being seen on a frequent basis, but they haven’t had a well visit in two years. If we combine the appointments, that seems to be less of a deterrent to parents to make sure a well visit gets scheduled.”

Dr. Pillsbury said they also use their practice management system to recall adolescents in need of well visits. And, patients and their parents who come in for a sick visit are automatically reminded of upcoming well visits.

“One problem we run into is that parents often wait until the last minute to schedule physicals before the start of the school year. Unless there’s a cancellation, it’s going to be tough to get patients in the day the parent calls and that can be a problem,” said Dr. Pillsbury. While educating families can be helpful, Dr. Pillsbury said they haven’t yet found a good way to solve this problem. Using technology such as a patient portal is going to be increasingly important for the practice going forward. “We’ll be able to send a message to everyone whose child is over 10 and remind them to schedule their appointment before the end of summer.”

These reminders are part of ongoing education that pediatric practices must consistently prioritize. Educating parents about the importance of well visits and the benefits of the medical home can take years of repetition to impart on families. But Dr. Pillsbury said she’s seen positive change in this regard.

Adolescents benefit from having an annual well visit that addresses the physical, emotional, and social aspects of their health during a transformation period. And, pediatric practices stand to benefit, too. By providing continuity of care for these patients, pediatricians improve clinical care and generate revenue from seeing patients that are already part of their patient population.

While there are still aspects of managing an independent pediatric practice that can be frustrating, Dr. Pillsbury said that she’s seen many positive changes during her career. “When I started practicing, a lot of children did not have a pediatrician. There was a shortage of primary care providers and most of the doctors in town did not take any Medicaid. That has definitely changed. We have far more providers and everybody takes Medicaid now. I’ve lived to see pediatrics change dramatically.”