A disconnect between medical resources and health care delivery

Imagine what health care in the United States could look like if we devised a system that was based on sound medical practice and proven cost effectiveness.  What if we put our brains, energies and passion behind designing the smartest health care system possible?

That was the question that kept poking through my train of thought as I read a study that appeared in the most recent issue of Pediatrics, the official journal of the American Academy of Pediatrics.  The study, out of UCLA, examined the association between length of well-child visits and quality of the visits, including things like developmental screening and anticipatory guidance.  No big surprise that the longer the duration of the well child visit, the greater the likelihood that the content of the visit was aligned with recommended practice guidelines from the AAP.  The discouraging news however is that one third of visits were reported as being less than 10 minutes in duration; these occurred to a greater degree in private practice.  Longer visits of 20 minutes or more made up 20% of the encounters, and were more likely to occur in community health centers.

The big winners in the pinch for time?  Guidance on immunizations and breastfeeding were offered in 80% of even the shortest visits.  The biggest loser: developmental assessments, which don’t even achieve a mediocre occurrence of 70% until we pass the 20-minute mark for visit duration.

What’s behind all this?  A profound disconnect between our medical resources and our health care delivery. No where has modern pediatric care evolved more dramatically than in the arena of well-child care and preventive medicine. What has not evolved along with our scope of knowledge is our delivery system.  Our fee for service approach to health care dictates that procedures and tests pay well while addressing a child’s emotional problem gets a doctor little more than a backed up waiting room.   From the patient’s view, underinsured children have to rely too much on emergency rooms, while insured parents can only get basic child rearing advice from someone with a medical degree. Health insurance companies and the pharmaceutical industry shape medical practice – and our collective health – through their reimbursement policies, marketing and aggressive lobbying.  So 25% of US children are on chronic medications, while half the children in pediatric practice are not receiving basic screening and advice. The obsolete business models that the health care industries rely on are like the tyrannosaurus-rex in the room, emphasizing expensive, short term quantity rather than cost-effective long term quality, while cognitive care – a high level of skill and expertise delivered face to face in a personal manner – is what is becoming extinct. Even as the scope and challenges of our health grow more complex, and chronic conditions overtake acute threats, we keep trying to squeeze our health care delivery into a model that was appropriate when you only went to a doctor to treat your pneumonia or have a farm implement removed from your foot.

It is not surprising that community health centers are associated with longer, higher quality well-child visits. The doctors are salaried, which means they are somewhat insulated from the array of financial disincentives that currently infuse primary care, like the need for rapid patient turnover.  The centers are also more likely to utilize a more rational division of labor, so that every issue doesn’t immediately make its way to the most expensive professional in the room simply because that is the only person who will get paid for the visit.  Nurses at all levels of skill are used for a wider scope of encounters, and there are often ancillary resources – nutritional and mental health services for example – that expand the kinds of services the patient receives, approaching the ideal of a comprehensive medical home for all patients.   It is also not surprising that the practice settings that are successfully evolving into medical homes are largely publicly funded.  By their very nature, they put patients’ best interest above profit, and have a vested interest in long-term outcomes as opposed to short term productivity.

So, back to the study from UCLA.  We know what every child should receive in the way of well-child care, and we know that quality primary care saves money in the long run.  We have professionals at all levels of training and pay scales capable of delivering high quality care.  We have incredibly skilled and dedicated pediatricians who can coordinate this kind of teamwork. So why are we wasting our time arguing about how to pay for obsolete delivery models and payment systems?  Why not design a system that does what it is capable of, and saves us money in the long run.

Imagine what health care in the United States could look like if we devised a system that was based on sound medical practice and proven cost effectiveness.  What if we put our brains, energies and passion behind designing the smartest health care system possible?

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine, from Chelsea Green Publishing. This post originally appeared on Progress Notes.

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  • Payne Hertz

    Imagine if we adopted a European-style medical system.

    Problem solved.

    Raising the payments for fee for service arrangements increases the profitability and therefore the likelihood of assemblyline medicine. Specialists get paid way more for consultations than primary care doctors do, but they are every bit as inclined to rush you in and out of the office as fast as they can. More money doesn’t equal better service.

    • Anonymous

      It’s not so much the money.  It’s the isolation from the expenses.  Public health clinic providers have more time  because they do not have the need to see more patients because they don’t care about the expenses. It’s the same with the patient’s side–if they are isolated from the cost, then the demand is high, one reason America has high health care costs.  Then why isn’t the demand high in European systems?  Because the government is able to put cost limits in place and offer fewer services on demand.

      • Payne Hertz

        America has high health care costs because of greed, fraud, profiteering, inefficiency and incompetence. There are less profit incentives in “socialized” systems therefore less incentives for excess, fraudulent or useless medical care and treatment costs less because profit adds to the cost of medical care. Patients are not isolated from the costs of medical care. I don’t know why this particular chestnut keeps surfacing again and again when it’s so patently false. Medical care is the number one cause of bankruptcy in the US. Even those with insurance who don’t go bankrupt pay out the nose for it, and people are often stuck in crap jobs to maintain some kind of medical benefits, and can lose those benefits if they lose the crap job. Then of course there is the huge toll in death, injury, pain and inconvenience suffered by patients every year in the US, the human cost of which vastly exceeds the monetary costs.

        Patients are by no means isolated from the costs in this system, but of course doctors are, right up to the point the 1 percent decides they are replaceable McWorkers too, which is what we are beginning to see now. Then you’ll see how ruthlessly indifferent triage due to medical cost cutting can be.

        Studies show that patients in socialized systems see their doctors more, but doctor visits are not the primary drivers of cost, expensive procedures and hospitalizations are. By having more of the former, you may cut down on the need of the latter and reduce costs overall while delivering better treatment. Of course the emphasis on preventative treatment in Euro systems rather than the more profitable after care we have in ours is also part of this.

        • http://www.facebook.com/people/Maggie-Keavey-Kozel/1383572933 Maggie Keavey Kozel

          Actually doctors are not isolated from the cost of our health care.  They are constantly practicing under a crushing system of financial incentives and disincentives that makes it impossible for them to practice the best possible medicine.  They are frustrated trying to get their patients the treatments they need, and begging insurance companies to be reasonable.  Many are working harder and harder as their incomes erode.  All of us -patients and health care providers alike -  are feeling the strain.

        • Anonymous

          Greed.  I agree that greed is in place, but most of it is from insurance companies and attorneys.  I said “most.”

          Doctors are not isolated from costs.  My costs are going up to run my practice at least at the rate of inflation, if not more.  My insurance rates to cover my employees went up more than 10% this year, yet the insurances who contract with me only want to increase payments 2%.  Lose-lose for the doctors, no?

          Seeing doctors more, which would not be “the primary drivers of cost” (and I agree) does not necessarily result in less cost overall, especially when it’s easy for those doctors to order more CT’s and lab tests “just to make sure”.  In others words, “just to make sure the attorneys don’t call me.” The vast majority of tests we doctors order are normal, but it is done to reassure both patient and doctor.  Socialized systems have procedures in place meant to keep the threat of lawsuits to an absolute minimum, and to reduce numbers of tests and procedures, but our system works to maximize those same threats.

  • http://www.facebook.com/people/Maggie-Keavey-Kozel/1383572933 Maggie Keavey Kozel

    I am not sure I agree with the reasoning that clinic doctors take more time because they “don’t care about expenses.” Rather they are protected from the punitive disincentives in our fee-for service system such that they can practice the way they were taught.  Once you takeaway the dysfunctional incentives that are now driving our health care system, cost-effectiveness is attainable.

  • http://www.facebook.com/people/Jeff-Frater/619980887 Jeff Frater

    I red this and I agree, but I keep reminding myself that the introduction of the third party payer in combination with a fee for service model is what led to the huge fiasco of a system we have now.  One or the other must be disconnected for a solution to be viable, fair and humane.  Since the third party payer is really a necessary evil due to the protects against catastrophic expenses, it is the FFS model which must be dismantled. 

    We need the third party payer to establish the system which rewards everyone (patient and provider) for wellness. 

  • Anonymous

    It is hopeful that more time visits will establish the forgotten art of listening and build the trust needed between the pediatrician and the child.  Long term benefits will assist the healthy developmental assessments of the child.  A smart delivery system does not exist in a vacuum.  Its intelligence relies on smart health care providers.  It is my opinion that your blog is the best article written by an MD who supports for the smart reasons the PPAC plan.

  • Anonymous

    It’s not the fee for service system that’s the problem. It’s that a physician’s time and advice is not valued as a service that’s the problem. Your Attorney’s and accountant’s time is considered a valued commodity. It’s high time that the doctor’s time be regarded similarly.