PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1283-1290

Physicians' Reliance on Specialists, Therapists, and Vendors When Prescribing Therapies and Durable Medical Equipment for Children With Special Health Care Needs

Raphael C. Sneed, MD^*, Warren L. May, PhD, and Christine Stencel, MA^§

From the Departments of ^* Pediatrics, Children's Rehabilitation Center, and  Preventive Medicine, University of Mississippi Medical Center, Jackson, Mississippi; and ^§ Private Research, Oakton, Virginia.

	ABSTRACT

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Objectives.  Physicians who care for children with special (health care) needs (CWSN) often must prescribe therapies and/or specialized, durable medical equipment (DME). Given this responsibility and the increasing scrutiny of prescribing practices by various oversight agencies, understanding the extent to which pediatricians rely on their own expertise when prescribing therapies and DME is an important area of research.

Methods.  As part of an ongoing investigation of physician preparedness for and practice in prescribing therapies, DME, or procedures for CWSN, we mailed surveys to practicing pediatricians in each of 2 statesOhio and Mississippiand to a senior resident at all identified pediatric residency-training programs. The surveys polled recipients as to who they would rely on themselvesspecialists, therapists or vendorsto make prescription decisions for a variety of therapies and DME of increasing complexity. We report results as proportions of returned and completed questionnaires. Comparisons among the 3 groups (pediatricians from Ohio and Mississippi and residents) were made with the use of ² analysis.

Results.  For some categories of therapy and DME, physicians and residents reported that they would take an active role in prescription decisions, and their reliance on specialty consultation increased appropriately with the increasing complexity of the device or therapy. However, respondents generally seemed to share responsibility rather than rely on themselves as sole decision makers for most categories; fewer than one fourth took sole responsibility. Reliance on nonphysician health care providers was evident for all categories; in some cases, up to half of the respondents would allow therapists to take over these decisions, and a small but significant percentage of physicians would entrust DME prescription decisions to vendors alone.

Conclusions.  Our findings indicate that many practicing pediatricians and those in training may be unwilling to assume sole responsibility in prescribing and managing therapies and DME for CWSN. Although the number who would rely on consultation with specialists is somewhat reassuring, we found that a significant percentage would turn to nonphysician health care providers and even vendors to make these decisions in some cases, raising liability implications, conflict-of-interest issues, and quality-of-care issues. To protect themselves and their patients from fraud and inappropriate prescriptions and medical management, pediatricians must become increasingly conscientious about complying with American Medical Association guidelines and federal and state laws regarding initiation and supervision of therapies and DME. We offer some recommendations that may help to address this problem.  Key words:  disabled children, rehabilitation, physician's practice patterns, fraud, health services research.

Physicians who provide care for children with special (health care) needs (CWSN) often are called on to prescribe special services, such as physical or speech therapy, and/or durable medical equipment (DME), such as braces or wheelchairs.^1-12 Collaborations between physicians and specialists, therapists, and vendors of specialty products contribute to the quality of care that these patients receive and provide physicians with valuable input and guidance to help them make prescription decisions.^36-12 However, government regulations dictate that physicians ultimately shoulder the responsibility for providing cost-effective, quality care for their patients, including prescriptions for special equipment or services.^13-17 Given this burden of responsibility, understanding the extent to which pediatricians currently rely on resources such as specialists, other nonphysician professional health care providers, and vendors in prescribing therapies and DME is an important topic of research. This is especially appropriate in regard to the current emphasis on physician involvement in early intervention programs and the American Academy of Pediatrics (AAP) promotion of the medical home.

On the basis of an ongoing survey undertaken to document physician preparedness for prescribing therapies and DME to CWSN, we previously reported a significant paucity of training in physical rehabilitation provided to pediatric residents and practicing pediatricians regarding rehabilitative care.¹⁸ Lack of training would be expected to have a significant impact on actual practices regarding CWSN. Therefore, as part of this continuing survey, we also investigated how senior residents and practicing pediatricians actually manage the physical care of their CWSN patients.

	METHODS

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We polled practicing physicians in Ohio and Mississippi and current residents from across the country (see reference 18 for details of the study design). In short, a survey was mailed to 1 chief or senior resident at each of 211 pediatric residency-training programs nationwide, which were identified via the Graduate Medical Education Directory, 1997-1998. Using the AAP Fellowship Directory, 1998 edition, we identified 2062 practicing pediatricians in Ohio and 321 in Mississippi. To balance the information obtained from physicians and residents, we took a computer-generated, simple, random sample of 225 physicians from each state. In the event that a questionnaire was returned undelivered, a replacement was selected randomly from the AAP Fellowship Directory. Two follow-up mailings were sent to those who did not respond to earlier queries to minimize bias introduced by nonresponse. No additional follow-up was done. Response rates were 87% for residents, 56% for Ohio pediatricians, and 46% for Mississippi pediatricians.

Our first goal was to survey the educational experiences of practicing pediatricians and physicians in training regarding care of CWSN and the prescription of rehabilitative products and services; the results were published in our previous paper.¹⁸ In the present article, we investigate the actual practices of postgraduate pediatricians and senior residents in prescribing and supervising therapies and DME for CWSN on the basis of responses of study participants concerning whospecialists, therapists, vendors, or the respondentwould make the final decision on prescribing certain DME, therapies, and procedures for their patients. As a cross validation, we inquired about their perceived role in an increasing hierarchy of expertise in therapy management chosen on the following criteria. Both determining the feasibility of gait training and spasticity management require knowledge of pathophysiology, prognosis prediction for functional attainment, and the various success rates and complications of different treatment options.^19-21 Therefore, these 2 procedures were believed to require greater expertise and knowledge than that of ordering physical, occupational, or speech therapy. Neurolytic procedures, including a variety of nerve and muscle/motor point blocks, are considered highly complex and specialized medical procedures as compared with feasibility of gait training and even spasticity management.

For each procedure or DME, we reported the proportion in each professional categoryspecialist, therapist, vendor, or selfthat respondents would include in the prescription decision-making process. In addition, we reported the proportion in each category to which physicians would defer the decisions for each of the procedures or DME. The results are listed in Fig 1, 2, and 3. For the therapies considered, we listed the results separately in Figs 1a, 1b, and 1c because each discipline has unique modalities and applications and should not be treated as a single unit under the umbrella of "therapies." Maximum bounds on the error of estimation at 50% response rate are 8.9%, 9.9%, and 7.3% for Ohio physicians, Mississippi physicians, and residents, respectively, without adjustment for finite population correction. Comparisons across Ohio and Mississippi physicians and residents were made with the use of either ² contingency table analyses or Fisher's exact tests with significance claimed if P < .05 and borderline significance if P < .10 without adjustment for multiple testing.

View larger version (53K): [in this window] [in a new window]   Fig. 1.   Who do you feel should make the final decision regarding the appropriateness of, type of, and formulating the guidelines for ordering each of the following (* indicates significant differences).

View larger version (60K): [in this window] [in a new window]   Fig. 2.   Who do you feel should make the final decision regarding the appropriateness of, type of, and formulating the guidelines for ordering each of the following (* indicates significant differences).

View larger version (55K): [in this window] [in a new window]   Fig. 3.   Who do you feel should make the final decision regarding the appropriateness of, type of, and formulating the guidelines for ordering each of the following (* indicates significant differences).

	RESULTS

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The physicians were asked who they believe should make the final decisions for ordering four of the major therapies for CWSN: physical therapy, occupational therapy, speech therapy, and therapeutic exercises (Fig 1). Approximately one fourth would include themselves as an authority for prescribing physical therapy (Fig 1a); only 10% to 15% would make the decision alone. Fewer than half would include a specialist in the decision-making process; between 17% and 30% would defer the decision to the specialist. Approximately two thirds would include a physical therapist; 33% to 45% would leave the decision solely to the therapist.

Similarly, when ordering occupational therapy (Fig 1b), 20% to 29% of respondents indicated that they would include themselves in the process; ~15% would rely solely on their own judgment. Only approximately one fourth indicated that they would consult a specialist. Approximately two thirds said that they would include an occupational therapist; nearly half would yield the final decisions solely to the therapist.

A little more than a quarter of physicians and just less than one third of residents would include themselves in deciding whether to prescribe speech therapy; approximately one in five would take sole responsibility (Fig 1c). Fewer than one fourth would include a specialist in the process, and even fewer would rely solely on the specialist. More than two thirds would include a speech therapist, and approximately half would entrust the decisions solely to the therapist.

When it comes to prescribing therapeutic exercises (Fig 1d), however, the majority of physicians do not seem to be willing to rely on themselves, perhaps because of lower confidence in their knowledge or abilities. Only ~10% of the residents and 5% of the physicians reported that they would make these decisions themselves. Although the respondents indicated that they were more likely to turn to a therapist than to a specialist, one third to one half of the respondents would seek the input of a specialist. Only approximately one fourth reported that they would rely solely on a specialist. Conversely, approximately two thirds would seek the advice of a therapist, and nearly half of the respondents would allow a therapist alone to make these decisions. The responses for these 4 categories of therapy seem to show a trend toward decreasing willingness to assume sole responsibility as complexity of the treatments and their diagnoses increased.

Physician willingness to be the sole decision maker in assessing the need for gait training is low, and only a few would take sole responsibility (Fig 2a). Most physicians and residents would turn to a specialist and/or a therapist. Approximately one half of the physicians and a smaller proportion of residents would turn these decisions over to a specialist. However, more than two fifths of physicians and one half of the residents would include a therapist; 22% to 34% would defer entirely to the therapist.

When making decisions about spasticity management (Fig 2b), only ~12% of the physicians reported that they would participate in the decision-making process; ~5% reported that they alone would make the final decision. These results are somewhat expected given the more complex nature of this service. The majority of physicians and residents would include a specialist; one half to nearly two thirds would rely solely on the specialist. This would be considered appropriate if the physician, who may not have expertise in this area, made the referral. However, 34% of Mississippi physicians would leave the decisions to a therapist, although fewer residents (21.3%) and even fewer Ohio physicians (12.6%) would rely on a therapist alone.

For neurolytic procedures (Fig 2c), the majority of respondents would rely on specialists to assess patient need. This is in accordance with our expectations and, perhaps, is an indicator of the validity of the questionnaire, because we would expect most physicians to defer such delicate procedures to a specialist unless trained adequately. Only a few of the respondents would include themselves in the evaluation team. Residents seem slightly but not significantly more self-confident. A few respondents would include a therapist in the process, and even fewer would rely solely on the therapist, an appropriate response for this type of procedure.

Regarding the major therapies for CWSN and other modality management (Fig 1 and 2), residents and practicing pediatricians seem to be generally unwilling to manage and supervise all treatments solely. As complexity increased, physicians appropriately did begin to include specialty consultation at an increasing rate. However, of some concern is the high reliance on therapists alone that our respondents reported for physical, occupational, and speech therapy and therapeutic exercises. Even for the more complex treatments, gait training and spasticity management (Figs 2a and 2b), a notable percentage of respondents (12.6% to 34.1%) would allow a therapist to be the sole decision maker.

DME seems to present even greater challenges to physicians and residents. When asked who they believed should make the final decisions regarding limb braces (Fig 3a), willingness to rely on themselves was low among both practicing pediatricians and residents. Fewer than 4% would include themselves in the decision process, and very few physicians were willing to take sole responsibility. Approximately 90% of the practicing physicians would include a specialist; 70% would leave the decision to the specialist. Only 5.4% to 10.3% of the practicing physicians reported that they would allow a therapist to make these decisions alone, but one fourth of the residents, who will be entering into practice shortly, reported that they would rely solely on a therapist. Although the numbers were low, it is of some concern that 2.1% to 4% of the respondents would entrust these decisions to a vendor alone.

Wheelchairs require more complex decision-making processes and potentially are a more expensive device. When queried as to who they believe should make the final decisions on ordering wheelchairs (Fig 3b), the respondents seemed to lack self-confidence; fewer than 1 of 7 included themselves in the process. Even fewer said that they would make the decisions themselves. By and large, most of the respondents would defer to a specialist or a therapist. Disturbing is that a large proportion of residents (41%) would entrust the decision-making process solely to therapists. One third of Mississippi physicians and approximately one fourth of Ohio physicians indicated therapists as the sole decision makers. Even more alarming is that nearly 10% of the respondents stated that they would allow a vendor alone to make the final decisions. Such practices could raise conflict of interest and liability issues for physicians.

Regarding the application of spinal orthosis (Fig 3c), which requires long-term, complex decision making and knowledge of medical pathophysiology and progression, very few respondents listed themselves as one of the final authorities in prescribing these braces; physicians never were willing to be the sole decision maker. The majority of respondents (81.8% of residents and >90% of practicing pediatricians) would include a specialist in the decision-making process or turn over the decisions to the specialist alone. This would be considered an acceptable practice as scoliosis and/or kyphosis often are managed by orthopedists, neurosurgeons, and occasionally other specialists, such as physiatrists. Approximately 12% of the physicians would include a therapist, but only a few would defer to a therapist alone, although these few may be engaging in questionable practices by doing so. In contrast, 25% of the residents would include a therapist as part of the team, and ~12% would leave the decisions to a therapist alone. A few physicians and slightly more residents would rely on a vendor in deciding whether to prescribe braces for the spine. Very few would allow vendors alone to make such decisions, but there are those who listed the vendor as the sole decision maker. The proportions of respondents that would rely on a vendor are similar for both limb braces and spinal braces. The high referral rates by respondents for spinal orthosis compared with the rates for braces or wheelchairs tend to validate our survey, as we would expect physicians to play a greater role in decision making for less complex equipment.

Finally, we gauged whether physicians' willingness to assume responsibility for these decisions changes with increasing experience in practice by asking respondents the year in which they completed their residencies and/or the length of their practices (Table 1). We found no pronounced trends in the proportions of those who were willing to be the sole decision maker in prescribing therapies and DME on the basis of years of practice after residency.

From an overall viewpoint of all therapeutic and specialty equipment categories surveyed (Figs 1 to 3), the use of specialty consultation did seem to increase appropriately with the increasing complexity of the therapy or the DME. However, reliance on nonphysician health care professionals as the principal decision makers was present in all categories, although with a decreasing but not absent role in decision making for more complex categories. Also, in all categories, physicians seemed to have relatively low confidence in themselves to be the sole decision makers, even for the less complex procedures and DME. Fewer than one quarter to one fifth of physicians feel capable of making final decisions alone in each of these areas. Equally notable is the role that "therapists only" play: 40% to 50% of the physicians stated that therapists alone should make the final decisions regarding ordering of certain therapies, and 26.4% to 40.9% indicated that therapists alone should initiate the ordering of wheelchairs. Of even greater concern is that a small proportion of physicians would allow vendors to make decisions regarding all categories of DME, and a larger number (7.3% to 9.1%) indicated that vendors alone should make wheelchair prescription decisions.

	DISCUSSION

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Pediatricians are charged by the AAP to ensure that their patients receive proper, timely, and cost-effective care, a responsibility that takes on additional nuances in the case of CWSN, who may require lifelong management of specialty therapies and/or equipment.^3-11 However, the results of our survey suggest that many practicing pediatricians and pediatric residents seem to be uncertain in their prescribing practices in these areas and often rely on outside sources for guidance.

Many of our respondents indicated that they would participate in the final prescription decisions in conjunction with specialists and/or therapists, which would be appropriate. In several cases, our respondents would defer to specialists, an acceptable solution, although one that may tax an already overburdened system. Somewhat disturbing, however, is evidence that in some cases a number of physicians and residents would feel comfortable allowing therapists to be solely responsible for prescribing therapies and devices. Although including the therapist as part of a comprehensive team would be an acceptable and desirable approach, turning such decisions over to a therapist alone may not be in accordance with federal and many state regulatory guidelines that require physician initiation of such prescriptions.^14,15,22 The most disturbing result of our survey is that some physicians and residents indicated that they would allow vendors to take an active role in prescription of certain DME and even defer such decisions to vendors, a clear conflict of interest and perhaps a violation of the patient's rights to receive quality care from a qualified medical professional.

The American Medical Association (AMA) has noted that Medicare (Medicaid generally follows Medicare guidelines in most states) requires physicians' approval for medical equipment and supplies, including prosthetics and orthotics.^13,14 Furthermore, the AMA has charged physicians with certifying medical necessity, diagnosis, prognosis, and duration of needs.^13,14 The Health Care Financing Administration (HCFA) and many state-regulated programs require physician initiation of all therapies and special equipment.^15,16,23,24 To protect themselves and their patients from fraud and unnecessary or inappropriate prescriptions and medical management, physicians must become increasingly conscientious about complying with AMA guidelines and federal and state laws.^13-1623-36

This burden of responsibility on the primary care physician raises issues of liability, especially in light of federal and state authorities' increasing emphasis on curtailing medical fraud and abuse.^{15,16,23,2529-31,33,36,37} Increasingly, federal and state agencies are scrutinizing physician providers as well as DME suppliers, home health agencies, and therapy agencies to discover inappropriate costs associated with prescriptions or overuse of services or equipment. Reports in the medical literature also document the concerns that physicians themselves have expressed about inappropriate requests and prescriptions for services and equipment.^25-29,32 Although most fraud and abuse are perpetrated by nonphysicians,^{15,17,26,32,35,36} the Office of the Inspector General notes that laxity may be a more common occurrence than deliberate abuse^15,36 on the part of physicians. For example, as a courtesy to patients, home health care providers, or vendors, some physicians have negligently or inadvertently signed off on certificates of medical need (CMN) that were supplied by vendors and contained false or misleading information.^{14,1726-28,35,36} Thus, it is still prudent for pediatricians to be knowledgeable in the areas of therapies and DME for CWSN. Although the primary care physician may not have direct financial involvement or be aware of inappropriate actions by other agencies, he or she may be drawn into a legal situation as a responsible party because of omissionfailure to supervise properly or be aware of the inappropriate actions of others.^17,30

At the same time that physicians are being reminded of this responsibility, they are facing increasing pressure and influence from a variety of other sources that have a stake in therapy and DME prescriptions. These sources include managed care programs, nonphysician health care providers, home health care agencies, and DME vendors, some of the very sources to whom our survey indicates that pediatricians may be willing in some cases to defer prescription decisions.

Managed Care Programs

Managed care programs expect the primary caregiver to be the "gatekeeper" who determines the need for and appropriateness of specialty consultations, therapies, and DME.^38-42 They also expect primary care physicians to rein in costs and ensure that only necessary and appropriate medical concerns are addressed in the most efficient manner. To function successfully as gatekeepers, physicians must have a sufficient knowledge base and confidence in their training to make appropriate decisions in assessing the needs of CWSN.^18,43 It is becoming increasingly less acceptable to claim lack of knowledge or training in these areas and automatically refer to a specialist or defer to other health care professionals. Physicians must take a proactive role in this arena.^39,42 They also must ensure that cost-cutting managed care programs do not force less effective therapies and/or DME on their patients.

Nonphysician Health Care Providers

The role of nonphysician clinicians, such as speech/language pathologists, physical therapists, and occupational therapists, as autonomous providers of patient care has been promoted and even increased in some states as expanded scope of practice.^2244-51 As our survey results indicate, many physicians and residentsat times more than 50% of the respondentsseem willing to grant therapists authority in decision making concerning therapies and DME (Figs 1, 2, 3a, and 3b). The AAP's policy statement on prescribing therapies and DME notes that "physical therapists often have the responsibility for ordering equipment and assistive devices."⁹ To clarify this statement, we point out that nonphysician health care professionals may participate in identifying needs and making recommendations for services and equipment. However, the AAP recognizes that the pediatrician, with 4 years of medical school plus 3 or more years of intensive training and professional commitment to quality care, is the most appropriate provider of pediatric primary care.^4,5 Although autonomy of nonphysician providers is increasing, physicians still are legally required by most federal and state-regulated programs to initiate and prescribe therapies and DME.^{13-17,22,48,49,52} Many commercial payers follow federal guidelines. Thus, deferring decisions to therapists may not be an acceptable practice in many states.

Home Health Care Agencies

A significant proportion of the primary care physician's role in therapies and DME may involve home health care.^8,1453-56 However, although the pediatrician may act as primary caregiver, his or her role often is mostly supervisory. Goldberg et al^53,55 noted that pediatric education previously has provided little guidance to physicians in the supervision of home health care for CWSN. Unfortunately, as reported by HCFA, some physicians have come under significant pressure tactics by home health care agencies to order certain services.^{13-1726-28,32,36} These tactics include the suggestion that if the physician declines, the agency will encourage the patient to seek another physician whose name is supplied by this agency and who will prescribe the services or equipment requested. But as federal guidelines strictly prohibit any initiation of therapies or DME by nonphysicians, pediatricians who sign orders that they did not initiate place themselves at risk of litigation.^15-17 Changes in Medicare law provide civil monetary penalties of up to $10 000 per claim, program exclusion, and possible criminal prosecution for physicians who fail to comply with program requirements, such as properly certifying the medical necessity of home health care.^15,29

Vendors

DME often is required for the management of CWSN. Perhaps the most common form of DME is limb braces, which would include ankle/foot orthoses, leg braces, wrist splints, and arm braces. Although our study focused on these items, apnea monitors and oxygen and ventilation systems for outpatient use are just a few examples of other DME for which the principles and concerns that we review also would apply. Many vendors of medical equipment are highly trained and reputable and can be a valuable resource for professional input to the primary care physician. However, it has been noted that only limited professional qualifications are necessary to set up a DME supply company.³⁵ The principal meaningful control of the system is a physician's determination that the service or equipment is medically necessary.^{13-17,23,2426-28,32,35} Unscrupulous vendors may use a number of tactics to pressure or influence physicians' prescribing practices.^{14,1526-28,32,33,35,36,57} On occasion, vendors may initiate plans of care for DME or present to physicians partially completed CMN for their signature before an order is placed or sometimes even after the equipment has been delivered.^{1726-28,32,35,36,52,57} By signing off on these plans of care or CMN after the fact, physicians put themselves in jeopardy of liability for fraudulent practice.^{13-15,1725-36}

It therefore is somewhat disturbing that up to nearly 10% of respondents to our survey said that they would let the vendor alone make wheelchair prescription decisions (Fig 3b). A few physicians and slightly more residents would rely on vendors in deciding whether to prescribe braces for the spine (Fig 3c). Very few would rely only on vendors, but there are those who listed vendors in each DME category as the sole decision maker (Figs 3a to 3c). This clearly is at odds with the AMA's recommendations and federal and state regulations as inclusion of vendors as initiators in prescription decisions could represent a conflict of interest.

Recommendations

In light of these pressures, we offer some recommendations that may help physicians clarify their roles and responsibilities and guide them in coping with pressures from different sources. More detailed recommendations are available from HCFA, AMA, and the American Academy of Physical Medicine and Rehabilitation.^14,15,58

Therapies and DME should meet clearly defined goals.^3,912-15 Guidelines and recommendations from the AAP Committee on Children with Disabilities suggest that therapy prescriptions should specify type, frequency, intensity, and duration along with treatment goals; they should not be vague or open-ended.⁹ Also, the prescribing physician should note any safeguards, contraindications, and special needs or conditions of the recipient and evaluate regularly the results of therapies and devices to make sure that they are meeting their goals. Physicians should always carefully review plans of care and orders for therapies and DME before signing to ensure that they are appropriate and avoid "rubber-stamping" prewritten plans of care or CMN. If a physician becomes aware that his or her name and identification number are being used by a facility long after he or she has ceased providing prescriptions, then that physician should take action to remedy this.^13-15,17,35

According to federal and some state guidelines, only physicians should determine whether home health services are medically necessary.^14,15,57 Physicians are strongly urged to review and document all orders for home health care services before signing them and avoid signing multiple, undated orders for the same patient. Physicians should not authorize provision of home health services to any patient whom they are not seeing regularly or for whom they are not providing care.^13-15,58

If possible, prescriptions for DME should indicate the need for built-in expandability to accommodate the pediatric patient's growth. It often is more profitable to suppliers to replace equipment rather than to make it expandable, so it behooves physicians to take responsibility for ensuring as long a useful life for costly equipment as possible for the sake of their patients. The AMA's code of medical ethics states that physicians should not be influenced in prescribing devices supplied by vendors in which the physician has a direct or indirect financial interest and should not enter into agreements with suppliers regarding the filling of prescriptions.^13-15 As there have been some reports of vendors' delivering a less expensive version of the DME than the physician prescribed and billing for a higher cost item, the physician should review the DME that the patient has received to ensure that it is the appropriate item.^{9,14,15,1726-29,32,35,36} A follow-up visit to the physician's office or communication with the patient's caregiver can quickly ascertain whether the correct DME has been delivered.

Most physicians and nonphysician health care providers are ethical individuals who serve their clients' best interests. However, there are reports that suggest that without some form of oversight and interaction, there can be tendencies among some physician and nonphysician providers to prescribe rehabilitative services that may increase benefits to the provider more so than to the patient.^59,60 Also, findings of incidents of fraud and abuse suggest the need for separating initiation of services and the provision of services for reimbursement benefits.

As noted by The Future of Pediatric Education II executive summary, "too many [pediatric] residency programs underemphasize this aspect [the care provided to children with chronic handicapping conditions] of pediatrics."⁶¹ We previously recommended increased training in the care of children with physical disabilities.¹⁸ The ideal arrangement for assessing the needs of CWSN is for a team of professionals to view the patient jointly and confer directly, but this is not always practical in the nonspecialty clinic setting. However, if primary care physicians have developed a sufficient knowledge base to supervise the appropriateness of therapies and DME, then effective communication can be maintained among the various individuals involved in the patient's case to ensure quality care. Physicians should insist on adequate communication and not accept vague statements such as "the patient is making progress" from other providers. They should feel free to make recommendations if needed or to ask appropriate questions if warranted. Some physicians may have concerns that federal requirements of physician supervision are unduly burdensome given the complexity of rehabilitative services and equipment and the level of knowledge, education, and documentation that they necessitate. However, the federal regulations require only that the physician initiate prescriptions and supervise and document the prescribed therapies' or DME's appropriateness. Review of such documentation should not require any more time and effort than are involved in writing and managing other prescriptions.

We already recommended several avenues that could be approached in pediatric training programs to increase physicians' knowledge in the area of prescribing therapies and assistive devices for CWSN.¹⁸ One option for practicing pediatricians is to identify specialists within their local or regional areas to whom they could refer patients or from whom they could seek assistance in handling therapy and DME prescriptions and supervision. Many areas of the country have specialized, multidisciplinary clinics with rehabilitation teams consisting of trained physicians, such as physical medicine and rehabilitation (physiatrist) specialists, developmental medicine physicians, neurologists, and/or orthopedists. These resources may include specialized state clinics for CWSN, university centers, private organizations for CWSN, or rehabilitation (outpatient and inpatient) hospitals and clinics.

	CONCLUSION

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The Future of Pediatric Education II executive summary has stated that "the care provided to children with chronic handicapping conditions continues to be problematic" but recognizes "pediatricians [as] uniquely qualified to provide this care."⁶¹ Oversight by physicians is both ethically appropriate and mandated by regulatory agencies. The prudent physician should perform this role judiciously, both for the patient's best interest and for his or her own safeguard. One of the strengths of physical medicine and rehabilitation is the strong concept, applicable to all medical professionals, of the multidisciplinary team management system: all partiesphysicians, nonphysician health care providers, suppliers, and, most important, the patient and the familybring their knowledge and expertise to the decision-making process in a collaborative effort for the best interest of the patient. With this approach, it is hoped that the issues of autonomy and competitiveness would be reduced by the recognition of the unique expertise that each professional and patient and family member offers.

	FOOTNOTES

Received for publication May 5, 2000; accepted Oct 10, 2000.

Reprint requests to (R.C.S.) Department of Pediatrics, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216-4505.

	ABBREVIATIONS

CWSN, children with special (health care) needs; DME, durable medical equipment; AAP, American Academy of Pediatrics; AMA, American Medical Association; HCFA, Health Care Financing Administration; CMN, certificate of medical necessity.

	REFERENCES

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