Everyday Pediatrics

Change for the good

Everyday Pediatrics is a monthly column written by William T. Gerson, MD, that will touch on issues related to the daily practice of office-based pediatricians.

As I complete my first three columns that have focused on the challenges of practice and the future we face as general pediatricians, I have been reminded once again by my patients and their families why I do what I do.

As most of you know, the late winter months seem to be the busiest in the office. No matter when influenza or respiratory syncytial virus season hits here in Vermont, March seems to be consistently the busiest sick call month. Perhaps it is because after beginning our winter illness season in October, the burden of repetitive viral illnesses finally overloads both immune and coping systems.

As I was seeing evening sick visits after a full office day recently, I closed the exam room door to be greeted by a family of mine whose parents are both public school teachers; the mom just returning to work after delivering a healthy boy 3 months ago, with the 2-year-old son being the ill patient with fever, cough, congestion and ear pain. Although not a diagnostic dilemma, the social and medical context of the visit reinforced one of the many joys and privileges of practice — the closing of the visit by an expression of gratitude by the family that I had been available to listen and care, and had been since a prenatal visit before the eldest’s birth. I kept my emotions of gratitude to myself.

Some days, the above scenario ends with the unanswerable question of why the last visit of the day often involves a child with the most tenacious ear cerumen, but most days contain many of the elements of the wonders of pediatric practice. What I have tried to express in these columns is my concern over the future and my hope that those of us who actually are seeing general pediatric patients and truly love what we do have a voice in the ongoing debate over the future of health care. We cannot, however, continue to practice as we have without embracing change while advocating for those things we hold most dear.

I am cognizant of the ease in which we reject change, especially at times of uncertainty. As a private practice pediatrician, I am also well aware of the costs of change and the unlikely improvement in reimbursement promised at the end of whatever cycle of “improvement” in which we are currently embroiled. Most importantly, I do not think we will embrace change unless we have first been invested in the process and believe in its motives.

Where are the touch points of change?

Quality improvement

We must embrace quality improvement in our offices. Unfortunately, most of us in practice do not speak the language or understand the processes involved. Quality initiatives have typically been imposed upon us by others and often in a punitive fashion. That is changing and is an aspect of maintenance of certification that, although often criticized, will ultimately pay off. Pediatrics, to its credit, is committed to publishing more articles on quality projects. I am especially pleased that we have excellent models of quality initiatives designed by and for pediatrics, in which the true goal has been to look for potentially better patient-focused practices within pediatric care. One only has to look at the Vermont-Oxford Network and the Pediatric Research in Office Settings network to see the best in outcomes research.

Accountable care organizations

The Affordable Care Act of 2010 describes accountable care organizations (ACOs) as groups of providers of services and suppliers working together to manage and coordinate care and whether meeting quality performance standards will be eligible to receive payments for shared savings. As the concept of ACOs is predicated on the primacy of primary care, it will be interesting to see how ACOs are formed and where pediatric care interfaces.

The debate on ACOs exists among the power brokers in health care, far from my hallways. Many organizations will attempt to qualify for ACO status to improve reimbursements and will need to capture the mantle of primary care. They will be large organizations, likely hospital networks, academic medical centers and existing HMOs. The new players to the field will need primary care but will want to control it and capture its enhanced reimbursements. Pediatric practices will need to understand the implications of such high-level managed care structures and will soon realize that pediatric care was not often central to the discussions of the organizing parties.

Medical home

Although pediatrics owns the concept of the medical home, the current delineation of the medical home has been co-opted by adult medicine to define its own goals for primary care and, not surprisingly, the additional reimbursements promised for such a “quality” transformation. In pediatrics, the concept is also evolving, leaving behind its original application to children with special needs to embrace all of pediatric care.

The medical home is being suggested as the prime mode for the provision of pediatric services. This nicely links to the adult model and allows integration into the enhanced reimbursement provisions of many payers. Unfortunately, there is no evidence to suggest that this is a better model for general pediatric care. Furthermore, it relies on the same flawed guideline-driven care that I have discussed in previous columns.

I only hope that pediatrics doesn’t mirror adult medicine and embrace the new medical home and simultaneously abandon hospital care to hospitalists. If as pediatricians we no longer see our patients and families when they often are most in need of our care (sick and well newborn care, acute and chronic hospitalizations), how are we providing best care?

Office-based pediatrics

Our current model of pediatrician-based primary care from infancy to young adulthood will not continue unless we integrate quality initiatives into our current practices in ways that do not change the essential culture of our practice. Unless we adopt the social change necessary for quality improvement, I would suggest we look to an outpatient model of advanced practice nurse-based care with some pediatrician-based oversight in the office setting, and a role for pediatrics as a consultant specialty.

Population medicine

As we strive for a new paradigm for pediatric office practice and advocate for children’s health while looking for quality and effective practices, I suggest we look at community-based public policy and away from some of our office-based interventions and preventive efforts. One of my objections to the current round of medical home and Bright Future Guidelines is the attempt to focus what we do in the office on areas of care that are surely more effectively addressed at the community level.

Ideally, there would be a partnership moving forward of pediatricians leading the charge to invigorate advocacy of population-based strategies that best addresses many of the most difficult challenges of pediatric care — cardiovascular health, mental health and injury prevention while also supporting the continuation of an office-based pediatrician-directed practice model that has adopted quality initiatives while maintaining and exemplifying the best in pediatric primary care.

William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board.

Disclosure: Dr. Gerson reports no relevant financial disclosures.