Almost two-thirds of adolescents in the United States don’t get the minimum recommended level of preventive health care services, according to researchers at UC-San Francisco who hope their new study will inform the health reform debate in California and across the nation.
“I hope Congress and policy makers in Washington and Sacramento will pay special attention to these important developmental years when they talk about health reform,” said Charles Irwin, the study’s lead author and director of the Division of Adolescent Medicine at UCSF Children’s Hospital.
Published online last week in Pediatrics, the journal of the American Academy of Pediatrics, the study examined several aspects of preventive care for adolescents, ranging from how many preventive visits kids get to counseling about health issues and whether patients had any time alone with their provider.Â
The study found 38% of children 10 to 17 years old had a preventive care visit in the past year. Of the 62% who didn’t see a doctor, lack of insurance and money were cited most often as the cause.
Preventive care is particularly important during adolescence, experts say, because many life-long habits that can affect health — smoking, eating, exercising — are developed during those years. Clinical guidelinesÂ the American Medical Association, the American Academy of Pediatrics, and other medical and governmental organizations have issued have long recommended that adolescents see a doctor or nurse practitioner at least once a year for a physical examination, shots or immunizations, and screenings for various conditions and behaviors.
Arguments To Change Payment Structures
A big part of the problem, Irwin says, is the way health care is paid for in the U.S.
“First, all preventive visits should be co-pay free,” Irwin said. “If you don’t have much money, but you do have insurance, how likely is it going to be that you take your perfectly healthy teenager to see the doctor when there’s a co-pay to be considered? TheÂ way things are now, it doesn’t make sense that anyone would go to the doctor if they’re healthy. If co-pays are not eliminated for preventive visits, I think health reform is really dead in the water.”
Irwin also said health insurers should change they way they reimburse providers to encourage preventive visits for adolescents.
“Physicians generally receive low reimbursements for preventive care,” Irwin said. “If I can make more money by seeing an acute care patient, what incentive do I have for scheduling preventive visits?Â Insurance companies need to see the long-range benefit in preventive care.”
Irwin also contends that physicians should be reimbursed for time spent counseling and diagnosing adolescents regardless of the diagnosis.
“If I see a young patient who’s not eating right or unable to sleep, and after talking to the patient for a while, I write down ‘depression’ in my notes, I very likely won’t get paid for that visit because the insurer will decide that’s a psychiatric condition and they don’t cover that,” Irwin said.
“That’s just crazy. If I write down the kid has a sleep disorder, I might get paid but that’s still a crap shoot. Ninety percent of insurance companies have a carve-out system to eliminate payments for situations like that. That’s just not conducive to encouraging preventive care,” Irwin said.
Counseling, Assessing Important Part of Adolescent Care
UCSF researchers assessed the extent to which doctors counseled patients or their parents about six specific health-related issues:
- Dental care;
- Eating habits;
- Wearing seatbelts;
- Wearing bicycle helmets; and
- Being exposed to secondhand smoke.
Fewer than half of the adolescents who had a preventive visit were advised about each of these issues, and only 10% were advised about all six.
“Preventive visits are really important opportunities for physicians and other providers to make an impact on young people’s lives, and we need to encourage that in any way we can,” said Sally Adams, a senior author of the paper and specialist in the Division of Adolescent Medicine at UCSF.
“It’s only been about the last 15 years or so we’ve seen these guidelines about annual visits for adolescents,” Adams said, “This is still a relatively new area and I think we should stress the value of physicians checking in on these important life decisions kids are making at that time in their lives.”
One of the best ways for providers to have an impact in adolescent lives is getting time alone with the patient during preventive visits, according to Irwin. Experts recommend children have time alone with doctors beginning at age 12 to provide an opportunity to discuss potentially sensitive issues like sexual activity and drug use. Among Â the adolescents surveyed who had a preventive visit, fewer than half reported having any time alone with their doctor.
Â “One-on-one time is important because it helps build a relationship between doctors and their patients,” Irwin said. “By learning how to communicate about their health needs early on, kids will be in a better position to discuss any issues of concern that come up in the future.”
Lack of Insurance, Money Key Factors
Using data from the Medical Expenditure Panel Survey — an annual national survey of families and medical providers about health care issues — researchers determined that income level and insurance status were key factors in determining whether adolescents got preventive care between 2000 and 2004, the time period of the study.
The study found that 48% of adolescents in high-income families had a preventive care visit in the past year, compared with 36% of adolescents in middle-income households and 32% of adolescents from low-income families.
Adolescents who were privately insured were more likely to have received preventive care in the past year than those who were publicly insured or uninsured.
“I think those kinds of findings are very good arguments in favor of advocating for insurance for everyone,” Adams said. “If preventive care is going to be an important part of our health care system — and everybody agrees it should be â” we have to make sure it’s accessible to everyone.”