Why are detection rates for developmental and behavioral problems so low, especially when most clinicians report that they routinely screen for disabilities?¹ The most significant obstacle to early identification is the type of screen used. Most providers rely on selected items from longer screening tests such as the Denver-II or on informal milestones checklists.^2,3 These approaches are not valid; they lack accuracy, and are the equivalent of putting a hand to a forehead to measure for a fever.

The following five self-assessment exercises will let you know how simple, valuable, and economical it is for you to make an investment in quality developmental-behavioral screening tools.

1   Referral rates

A simple way for a practice to assess the accuracy of their early detection efforts is to look at rates of referral to early intervention programs. Is it 1 out of 100 patients? One out of 200? Would you be surprised to know that the rate should be 1 out of 6? The Centers for Disease Control and Prevention found the prevalence of disabilities to be 16% to 18%. In several pre- and post-studies, when practices began using accurate screening tools, their referral rates increased to match the prevalence of disabilities.^4,5 Even so, referral rates change with age: We should be finding problems in about 1 out of 25 2-year-olds, 2 out of 25 3-year- olds, and in 3 out 25 4-year-olds-detecting the other four percent around age 5 - 8 years.

2   Visit time

A second obstacle to early identification is the misperception that screening with good tools takes too much time. But this must be compared with the time spent not screening effectively. A worthwhile practice-assessment exercise is to look at the time currently spent eliciting children's developmental skills, and having parents describe what their children can and can't do. Include the time spent on "oh, by the way" concerns that disrupt schedules-these "grenades" decrease sharply when parents have a chance to express concerns in writing prior to the encounter. Also estimate time spent discerning parents' agendas. Because screening tools elicit parents' concerns beforehand, they enable the encounter to be focused on issues of interest to families-thus also enhancing "the teachable moment."

Quality screening tests designed for pediatric clinics-PEDS, ASQ, and PEDS:DM-are typically completed by parents in waiting or exam rooms. That frees providers to concentrate on the more important tasks of making referrals and educating parents about behavior and development. In practice, most clinicians find that deployment of good tools actually saves time.

3   Reimbursement

Worries about costs and reimbursement have held back many practices from adopting good tools. So a third exercise is to view reimbursement before and after implementing a good screening tool.

Reimbursement is only assured when quality instruments are used correctly, and only when billed correctly. When a screening test is performed along with any evaluation and management service (e.g., preventive medicine or office outpatient), the modifier -25 should be appended (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The procedure code 96110 is used to indicate that screening occurred (if two or more screens were administered add X2, X3, etc.). In 2005, the Centers for Medicare and Medicaid Services published a total relative value unit (RVU) of 0.36 for 96110, which amounts to a Medicare payment of $13.64. None of this can guarantee that a valid claim will be accepted, so the American Academy of Pediatrics (AAP) is willing to help with denied claims via their Coding Hotline: 800-433-9016, x4022, or at aapcodinghotline@aap.org.

The RVUs do not cover a physician's time. This means that screening is largely a staff function, and thus staff training and commitment to determining the optimal work-flow is essential. Figure out if screens should be distributed to families in waiting rooms or exam rooms and who will score the screen, attach results to the chart, and create referral letters.

The costs that should be subtracted from revenues include purchasing a quality tool (or tools: for practices with skilled nurses or developmentalists, more in-depth measures could be useful). The per-visit expenses of these tools range from $0.02 to $0.50, from consumables purchased from publishers, or photocopying costs, when permitted. Quality screening tests are expensive to develop, maintain, and translate. Ensuring the tests are applicable to children of various socio-economic backgrounds residing anywhere in the US explains their cost.

Since referral rates will increase with good screening, the reimbursement also needs to recover the cost of time spent referring. That can be reduced by streamlining via referral templates, consent forms, and a good list of local resources. But overall, practices should find that using quality screening measures is a profit center.

4   Referral Resources

A fourth barrier to the adoption of quality screens is the misperception that referral resources are lacking. This is often due to the rarity of non-medical providers behaving how subspecialists do, by calling after referrals are made, sending test results, collaborating in decision-making-and thus reminding clinicians of their services.

The early childhood community is, in fact, rich with resources. Every county has free early-intervention services to qualifying children that are of good quality. Head Start and Early Head Start programs exist everywhere. Good preschool and day care programs are also a form of intervention. Local parenting classes and Internet-based parent-education services abound.

So in the spirit of self-assessment, practices should look at both known referral options and collaboration with non-medical providers, to compare against those suggested by the early intervention community. To facilitate implementation of a screening initiative, staff could be asked to compile and laminate a list of options to post in each exam room. Parents, while waiting, can see these too-making it easier when referrals are indicated.

5   Satisfaction

With so many undetected children, what is the toll on parent satisfaction with services from pediatric clinics? What happens to families with undetected children? Many simply leave the practice and find services elsewhere. In contrast, Blue Cross-Blue Shield of Tennessee found that when requiring providers to use a quality screening tool based on parents' concerns, attendance at well-visits increased.⁶

PRACTICE RESOURCES

For information about options among accurate screening tools: www.dbeds.org (The AAP's Section on Developmental-Behavioral Pediatrics Website) has descriptions of measure with links to publishers, tutorials for clinicians staff, information on disabilities, etc.

For advice about training and implementation of tools: www.developmentalscreening.org Harvard University's guide to considering work-flow, overcoming opposition, getting started with screening, etc.

www.pedstest.org has slides shows offering training and case examples on several screens, downloadable and customizable parent education handouts and referral letter templates, a list of common questions and answers about screening, services and referral, and an active discussion list on issues in early detection.

www.medicalhomeinfo.org The AAP's Medical Home Initiative has information on billing and coding for screening, guidance on care-coordination, a helpful email newsletter, suggestions for how to approach carriers to improve reimbursement for screening, etc.

For finding local services:
www.nectac.org. Links to State, regional and local early intervention and testing services for young children with suspected or known disabilities

www.ehsnrc.org/ Help finding Head Start Programs.

www.childcareaware.org and www.naeyc.org Assistance locating quality preschool and day care programs

www.patnc.org Information about parent training classes.

References

1.   American Academy of Pediatrics, Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening. Pediatrics 2006;118:405

2.   Sices L, Feudtner C, McLaughlin J, et al: How do primary care physicians identify young children with developmental delays? A national survey. J Dev Behav Pediatr 2003;24:409

3.   Sand N, Silverstein M, Glascoe FP, et al: Pediatricians' reported practices regarding developmental screening: Do guidelines work? Do they help? Pediatrics 2005;116:174

4.   Earls MF, Hay SS: Setting the stage for success: Implementation of developmental and behavioral screening and surveillance in primary care practice-the North Carolina Assuring Better Child Health and Development (ABCD) Project. Pediatrics 2006;118:183

5.   Schonwald A, Chan E, Risko W, et al: Routine developmental screening implemented in primary care settings: Provider attitudes, knowledge, and practice. Presentation to the Pediatric Academic Societies Annual Meeting, May, 2007

6.   Smith PK: BCAP Toolkit: Enhancing child development services in Medicaid managed care. Center for Health Care Strategies, 2005
Available here. Accessed June 14, 2007

7.   Bethell C, Peck C, Schor E: Assessing health system provision of well-child care: The Promoting Healthy Development Survey. Pediatrics 2001;107:1084