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The ‘cost’ of health care reform
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Look in the doubt we’ve wallowed
Look at the leaders we’ve followed
Look at the lies we’ve swallowed
And I don’t want to hear no more
— “Civil War,” Guns N’ Roses, 1991
The best preparation for tomorrow is to do today’s work superbly well.
– William Osler, MD, founding professor at Johns Hopkins
Affable, accessible, longitudinal, comprehensive, safe and high-quality medical care is, and has always been, what we strive for in general pediatrics. Money can be saved by the experienced provider identifying significant illness early and intervening in an effective manner to prevent excess costs associated with complications and avoiding unnecessary tests, procedures, hospitalizations and expensive pharmaceuticals. Even more improved outcomes and lower costs can be seen with coordination of care for those with serious chronic illness.
Culture of quality improvement
A commitment to excellence in clinical care going forward will also clearly require embracing a culture of quality improvement. Although office-based general pediatricians should be the leaders in any change to pediatric care, one of the emotional battles I face in practice today is balancing the competing impulses noted above — not listening to the painful administrative chatter while striving to practice superb care.
William T.
Gerson
Money is not really the issue in pediatrics, at least not in the same way as in the reforming of adult care. Investing in the true well-being of children is a public health and public policy issue in which our offices can play a significant role as both providers and advocates, but in which the major determinants of health and well-being are influenced primarily by family income and community resources. Most children in the United States are healthy and require little in the way of managed care. The dominant issue affecting the success of children is the socioeconomic status of their families and the closely linked environment in which families live. Modification of these issues requires a functioning family and community — and a nation that cares.
While care for children with special health care needs more closely aligns with the cost and quality improvement models of adult care within the rubric of the medical home, the vast majority of children’s health care needs will not see significant improvement by altering current practice. Furthermore, the required investment in change comes at a hefty cost, including increased levels of bureaucracy highlighted by administrative overload and practice modularization. Total spending is the key variable, not the more commonly measured medical costs, when evaluating new models of care (of course the actual issue is quality/safety/satisfaction).
Value of innovation
The value of innovation must always be measured against the cost associated with change. Real money will follow that already spent on federal, state and insurance administrative overhead to entire new levels of administrative “help” — practice facilitators, consultants and IT expansion to allow electronic health record (EHR) synchrony (or not), and quality metrics determined at some distant location that mimics that of the Voyager 1 spacecraft. All these levels and more become integral to the new bureaucracy of the medical home and meaningful use — and we as pediatricians lose the opportunity to affect change at the office level that is more reflective of the exciting potentials in pediatric care.
Questionable success of models
I do not dispute the thought and dedicated work that has gone into designing care models. I do challenge their likely success and the resulting diversion of time and money from direct services to children in need. Co-locating or community sharing of dedicated and skilled pediatric social workers and mental health professionals would likely be more efficient, less costly, and provide high quality care at less overall cost than any current model under development, particularly in addressing the many “hidden morbidities” of childhood we now face. A model that is not only administratively cumbersome but also contains built-in metrics to evaluate usefulness — admittedly in good faith — but for which helpful data let alone the ability to measure outcomes are lacking, is destined to fail. Short-term goals will be defined that have little meaning, and long-term outcomes will escape study.
I know that high costs have been the prime motivator for the recent wave of health care reform, but efficiency must not be a substitute for quality, nor impact on compassion. I have no doubt that innovative models of care will proliferate. Focus will be on alternative providers — some in new settings — new technologies, such as EHRs, and clinical guidelines with proposed improved linkages of care provision. Although these new models will promise improved outcomes and lower cost, they will, as most have, fail to deliver on either. A better future relies on investing in change at our office level, utilizing the depth and breadth of our pediatric knowledge and commitment to care.
Enhance positive reform
Many of us in practice aspire to be individualists deflecting the push to conform. The risk lies in simultaneously being deceived by the perception of our own superior quality of care. The result is the slow adoption of proven quality processes and lost opportunities to participate in efforts to determine better practices. Practicing pediatricians, leaders at the local level, are a requirement for fruitful reform.
To ensure success we must coalesce as groups of individuals without losing our individuality, we must become efficient without losing our compassion, and we must learn to interpret current performance data and evaluate ourselves and others within a defined identifiable and agreed upon goal of improved quality. Change must begin with us, include us, and should be defined by us.
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Disclosure: Gerson reports no relevant financial disclosures.