MAY • 2019
In May We Immerse

As cherry blossoms achieve full bloom and winter rains are replaced by warm sunny days,
We hear our chapter members’ many interests and expertise, to paraphrase
Celebrate and learn from a leader of private practice and an elected official of our community
And explore ways to address the future of foster care and our fluency.
President's Column
John I. Takayma, MD, MPH, FAAP

As cherry blossoms achieve full bloom and winter rains are replaced by warm sunny days, as forms for camps and schools inundate our offices, and as graduating residents prepare for a new work life, I can’t help but reminisce and anticipate simultaneously. We just held our quarterly board meeting and I was reminded of the vast range of interests and expertise our members have: diversity and inclusion, mental health, immigrant health, global health, practice management, and screening for adverse childhood events. We also learned that the most current and compelling topic was the measles epidemic. Although clustered in New York and Washington, primary care pediatricians were contending with “if and when” to provide early doses of the MMR vaccine and how to prepare practices for possible exposures ( https://www.cdc.gov/measles/index.html ; www.healthychildren.org ; https://www.aappublications.org/news/2019/04/19/measles041919 ). This was another reminder of how important it is to achieve universal childhood immunization.
Pediatric Mental Health Day is today, May 4, 2019, in San Jose. Yes - it’s too late to register - however, given how many people registered and how many more have signed up on our wait list, we plan to offer this curriculum again! Speaking of mental health, I was recently asked to share thoughts on how we nurture ourselves to create personal well-being and stay fresh professionally. Here is my top five: (1) Don’t read email first thing in the morning; it can heighten anxiety and keep you from staying on track. (2) Exercise regularly. (3) Limit alcohol. (4) If you have to sit for long periods of time (i.e., in front of the computer), stand up and walk around every time you have completed a task, look outside the window and appreciate nature! (5) Before entering a patient room, pause and check the name and room, and take a breath and remember not to bring in any leftovers from seeing the last patient.

Chapter officer and board elections will be held in late May - look for an email from the Academy office in Itasca. Please vote! Finally, we’re about to release the new and completely revamped version of our chapter website, in late May or early June! Let us know what you think. In the meantime, enjoy spring before preparing for the summer.
Lawsuit Win Against Molina, Blue Cross, and Health Net
Ravinder Khaira, M.D., M.P.H., F.A.A.P.
Sacramento Valley Member-At-Large, California Chapter 1 AAP Board

The Patient Protection and Affordable Care Act (PPACA) of 2010 provided millions of individuals with healthcare. In an attempt to entice providers to care for these patients the PPACA had a provision, referred to as Article 1202, built in to incentivize providers to care for these patients. Article 1202 provided a boost in reimbursement from Medicaid to Medicare rates for certain CPT codes for services provided from January 1st, 2013 to December 31st, 2014. Provider billed charges would be submitted from the health plan to the Department of Healthcare Services (DHCS) which would then forward the encounter to CMS. After an internal adjudication, CMS would send the difference, Medicare minus Medicaid, back to DHCS which, in turn, would send the payment to the health plan for eventual payment to the provider. DHCS provided ‘crosswalks’ to delineate payments. The link is here .

The payments for a single patient would be substantial. For example, an established 2 month well child visit including 4 vaccines would reimburse the provider $62.86. However, Medicare pays $173.67. Thus the difference of $110.81 would be sent to the provider. My pediatric clinics serve over 25,000 patients in 4 offices in and around Sacramento County. We would perform over 250 physicals per day; about 70% were for Medicaid recipients. It doesn’t take much math to realize that Medicare reimbursements would be substantial.

I began to notice irregularities with reimbursements as early as March of 2014. The 3 health plans at issue were Molina, Blue Cross of California, and Health Net. Payments were inadequate and none provided EOBs for proper reconciliation. Further, we were unable to obtain answers from the health plans. In November 2014, I formally filed for a ‘Fair Fast and Cost Effective Resolution’ and provider disputes. Subsequently, all 3 health plans went silent. Attempts to obtain help from DHCS and DMHC were ignored 

In March 2015 I filed lawsuits against all 3 health plans. In June 2015 Molina offered to formally mediate. This resulted in a mutually agreeable settlement. However, both Health Net and Blue Cross hired the same law firm and decided to litigate. Thus began an arduous and very expensive lesson in the American judicial process. My Blue Cross contract required binding arbitration. In July 2017 during arbitration Blue Cross admitted to withholding payments due to a technicality which the arbiter agreed. Blue Cross of California was able to withhold and retain over 1.4 million dollars of ACA funds. The same argument by the same attorney was used for Health Net. However, these cases were not contractually adjudicated through binding arbitration. Instead it was fought in county court. A few days prior to setting a court date Health Net offered to mediate. In February 2019 a mutually agreeable settlement with Health Net was obtained.

Despite the rigor I would do it again. We as physicians are not trained in business, or contract negotiations. Yet success in private practice requires a working knowledge.

The Sacramento Business Journal also wrote an article and can be viewed here .

Switching From Advocate to Candidate: Member of the Board of Directors of the Sequoia Helathcare District
Aaron Nayfack, M.D., M.P.H.

This past Fall, after years as a pediatrician-advocate, I took the plunge to become a pediatrician-candidate. I ran for, and won, a spot on the Board of Directors of the Sequoia Healthcare District. Very briefly, the Healthcare District collects 1% of property tax revenues from South San Mateo County and distributes it back into the community for health and wellness programs. Switching from advocate to candidate was not an easy decision and there is a lot more to say about running for office that can be fit into this brief article. In my opinion, the two most important elements are having a narrative about why you are running and then meeting with as many voters as possible and sharing that narrative with them. For me, that included creating a website, meeting with other local elected officials to get endorsements, sending out mailers and most importantly knocking on doors. The door to door campaigning, while time consuming, was by far the most enjoyable aspect of the entire campaign. My take home message to you is that as pediatricians, we are respected members of our communities. When we have the courage to speak out, our neighbors will often stop to listen.

So, what’s it been like on the other side of the advocacy table? In the proverbial “Room Where it Happens” for you Hamilton fans? It’s only been about five months since I took office and I have to say my learning curve has been steep, but my past experiences with the AAP have proven invaluable. Board service and advocacy work have helped me to understand the nuances of speaking out as an individual vs speaking out with the weight of an organization behind me. After many meetings in the past with other elected official at legislative days, I felt at ease taking office and working collaboratively to get things done. The highlight so far is the feeling that my ideas/priorities/experiences can quickly affect my local community. At my very first meeting, a proposal was discussed to partner and support an organization working with children 0-5 on early developmental support. As a Developmental Pediatrician, it felt great to share my experiences and see how quickly that translated into potential benefits for all of the kids in my county. So, while it definitely took a lot of time/effort to go from advocate to candidate to elected official, the experience so far has been fantastic. If any of you are considering it, please feel free to drop me a line. I’m happy to advise, consult or knock on doors for any of you!
Foster Care: The Good, the Bad and the Hope for the Future
Katy Carlsen, M.D., F.A.A.P.

“Every kid is one caring adult away from being a success story.”
Josh Shipp, author, motivational speaker and former foster youth.
You should all be commended for the hard work, dedication and patience you have shown in serving the children and youth in the state of California. The work many of you do to improve the lives of children and youth in Foster Care is both admirable and I am sure frustrating due to the current system inefficiencies on many levels. As May is National Foster Care Month, I am honored to be able to share some good news in regards to some of the changes in California’s Child Welfare system as well as some federal based funding sources for future preventative services to avoid foster care placements for many at risk youth. 

In addition we, as members of the Foster Care committee, believe that emphasis to prevent at risk children and youth from family removal is truly the way forward to improve our system of child welfare in this country. On the heels of Child Abuse Prevention Month, this article will hopefully guide you through some of the current efforts to do just that. I hope to provide resources and website links to help those who share my passion for finding collaborative answers to these complex questions. But also, I would like to ask any of you interested in learning more about foster care health issues or in educating our membership with your own expertise on this topic, please consider becoming a member of our newly rebooted Foster Care committee!

Current State of Foster Care in California :
  • About 62,000 children are currently living in foster care placement within the state of California, with approximately half of those living in the 48 counties covered by CA Chapter 1 of AAP.
  • Majority of new placements are under 1 year of age.
  • Support services and access to mental health services access has been a key concern of all the pediatricians our foster care committee has been able to survey
  • Disruptions of placement accounts for much of the additional trauma placed on children and youth in foster care. Many children are placed with five or more families prior to aging out of the system.

Children and Youth in Foster Care are deemed by the American Academy of Pediatrics as children with special health care needs .
  • Children and youth in foster care have experienced at minimum 2 Adverse childhood experiences with many scoring as many as 8. As we know these ACES can lead to not only current behavioral and medical issues in the child but also long term medical disease processes and morbidity.” The Deepest Well, Healing the long term effects of Childhood Adversity. Nadine Burke-Harris, MD FAAP California Surgeon General.
  • Each county has a public health nurse program (Health Care Program for Children in Foster Care or HCPCFC) to serve these children and youth in a case coordination model and may be a huge asset to pediatric providers doing this work.
  • Promotion of Protective Factors is very helpful in addressing the history of abuse and neglect these children have faced both within foster care and within biological family settings. A wonderful fact sheet regarding this topic is https://www.childwelfare.gov
  • Court Appointed Special Advocates or CASAs can also be wonderful allies to assist in caring for the foster children and youth and have the power to present concerns to the court or other resources to help the child achieve success. www.californiacasa.org

What is the current California child welfare law reform known as Continuum of Care Reform (CCR) and how will it affect foster children and youth?
Continuum of Care Reform (CCR) is a term which was developed and subsequently implemented into California Law in 2015 with AB 403, with follow up legislation in subsequent years. The goal of this effort is to significantly reduce the use of group homes and congregate care facilities with the vision of all children and youth in foster care are loved by-and living with- resource families which include and prioritize relative placements.
CCR Implementation has been highly collaborative with state and county leaders working with stakeholders to address challenges in transforming our current child welfare system to trauma informed, family based care.

Key part of any successful initiative is the details and this one is focused on Quality Parenting Initiative (QPI) which is a strategy of the Youth Law Center again a strength based approach . Focusing on quality parenting skills for all children in the child welfare system no matter where they are placed, making families the primary intervention for kids who are at risk for abuse or neglect. Quality Parenting Initiative lays out the issues these children face due to their history of trauma and educates resource families as to the absolute necessity of interventions and recognition of triggers for the child to model positive parenting if working with birth parents as well.

Future Hope for Change in Child Welfare: Family First Prevention Services Act (FFPSA) :
This new federal legislation was enacted on February 9, 2018 as part of the Bipartisan Budget Act of 2018 (HR 1892). Most of the implementation is not in place as of yet being that it is federal law with some flexibility upon the states in their implementation plan. Here are four fast facts for your general knowledge:

1. Eligibility for prevention services is without regard to income, eliminating the 1996 AFDC look-back requirement for children eligible under the new FFPSA provision. Eligibility is based on state/county assessment of child as being “at imminent risk of entering foster care.”

2. Title IV-E , the primary source of child welfare funding, can now be used for a specified set of prevention and aftercare services for these youth. Previously these funds could only be used for children already placed in foster care. This change opens funding to birth parents to help pay for mental health and substance use disorder treatment as well as in home parenting skill based instruction .

3. Services must meet new evidence-based guidelines to be reimbursed and fall into three categories of
a. Promising Practice: Created from an independently reviewed study that uses a control group and shows statistically significant results
b. Supported Practice: Uses a random-controlled trial or rigorous quasi-experimental design. Must have sustained success for at least six months after the end of treatment.
c. Well Supported Practice: Shows success beyond a year after treatment. At least half of a state’s spending on prevention services claimed under FFPSA must be in this category.

4. Prioritizes placement in family-like setting, including relatives and foster homes, and significantly reduces group homes and congregate care as a federally funded placement option.
a. Congregate care/group home federal reimbursement limited to 2 weeks unless the home meets specified requirements
b. Time limited placements in newly created qualified residential treatment programs (QRTPs) for children with emotional and behavioral disturbances
c. Exceptions include use of congregate care for prenatal, postpartum or parenting support for youth in foster care, supervised settings for children eighteen or older, and programs for youth who have been victims of and/or are at risk of human trafficking.

As you can see the federal legislation fits nicely with the already implemented goals of California Child Welfare Continuum of Care reform efforts. They both focus on strength based approaches to strengthen adults both foster/resource and birth doing the work of caring for children and youth in foster care. The federal legislation takes it a step further in hopefully providing services to families at risk for children being removed from the home in the first place.

Overarching Principles to Providing Pediatric Care to Foster Children
  1. All children in foster care are children with special health care needs just by the fact they are in out of home placement
  2. All children and youth in foster care deserve mental health/behavioral health assessment immediately or as soon as possible after placement away from birth family.
  3. Care coordinators are incredibly useful to manage the ongoing resource based services outside of the general pediatric providers purview.
  4. Learn the resources and get the contact information for your county HCPCFC nursing program and CASA program in your area to help you serve these children and families
  5. Advocate for better mental health service provision and reimbursements for care coordination and services whenever possible.
  6. Review the technical report and policy statement from October 2015 Pediatrics to learn the best visit frequency and need for close supervision and follow up for these complex children.

Other Resources:
  1. California’s Children Report 2017: www.cwla.org
  2. Child Welfare Gateway: www.childwelfare.gov
  3. Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics October 2015, volume 136 Issue 4: https://pediatrics.aappublications.org/content/136/4/e1131
  4. California Child Welfare Co-Investment Partnership: Insights volume XVL Winter 2018/19: http://co-invest.org/wp-content/uploads/Insight_XVI_Brochure_Winter2018_Final_digital.pdf
  5. Foster Care Statewide Task Force: http://www.cfyetf.org/about.html

As pediatricians and front line advocates for children’s health and development, it is imperative that we help train our staff and ourselves on the important role of ACEs in the lives of children we serve. In addition, as mentioned in last month’s feature article on child abuse prevention, it is important to focus on resilience and protective factors to help the at risk youth and families avoid the cycle of dysfunction which comes from the disruption of foster care. The legislation described above are two important changes in Child Welfare in the state of California as well as the nation at large. But legislation is not how lives are changed. As Josh Shipp describes in his own life, it took the perseverance of a single caring adult to reach him and every child deserves that chance to be successful!

I hope this article has been helpful and I welcome any questions or interest you might have in foster care for our California Chapter 1 area. Feel free to email me at katypc64@gmail.com .

Katy Carlsen, MD FAAP
Co Chair Foster Care Committee
California Chapter 1 AAP.
Upcoming Events for Your Benefit

Open Board Positions: Interested in an active role in the AAP California Chapter 1? Consider running for open AAP California Chapter 1 Board positions:
  1. North Valley Member At Large - Includes counties Butte, Colusa, Glenn, Lassen, Modoc, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Yuba
  2. Central Valley Member At Large - Includes counties Alpine, Amador, Calaveras, San Joaquin, Stanislaus, and Tuolumne
  3. North Coastal Member At Large - Includes counties Del Norte, Humboldt, Lake, Marin, Mendocino, Napa, and Sonoma
More information is in this Call Out here . If interested, email info@aapca1.org


New California Child Care and School Immunization Regulations go into effect on July 1st, 2019.
Check out the California Department of Public Health Guidelines here


Resident Sponsorship for the AAPCA Legislative Day on May 20, 2019
The AAPCA Legislative Day at the Sacramento capitol is a day of training on how to advocate on policies of your interest and includes visits with your representatives. If you are a resident, AAPCA1 will pay for your travel to Sacramento. If interested, contact us at info@aapca1.org


Adolescent Vaccinations & Wellness Grant Program for AAP Chapters – Due May 31
Interested in projects and programs to increase adolescent immunization rates? Please email us at info@aacpa1.org . This grant opportunity, supported by Merck, will provide six chapters $21,500 each to increase adolescent immunization rates! View the RFP , application , and learn more on the Block Grants page .


AAP Hub & Spoke QI Opportunity
As an extension to the AAP HPV quality improvement (QI) initiative, there is an opportunity to gain additional QI knowledge and learn from each other at the upcoming AAP’s 2019 Hub and Spoke Quality Improvement Training August 23-24 in San Diego, CA : This training will have two tracks and two presenters. One track will be QI Basics 101 and the other will be QI Intermediate. If you are interested, please contact us at info@aapca1.org
October 5, 2019:  Advocacy Training Day, San Francisco

October 25-29, 2019:  AAP National Conference & Exhibition, New Orleans

November 21-24, 2019: AAP California 41 st Annual Las Vegas Seminars
December 7, 2019:   Pediatric Puzzles Interactive CME Conference, SF

Our mission is to promote the optimal health and development of children and
adolescents of Northern California in partnership with their families and communities, and to support the pediatricians who care for them.


President: John Takayama • Vice President: Raelene Walker
• Secretary: Janice Kim • Treasurer : Nivedita More Past President: Zoey Goore
Executive Director: Isra Uz-Zaman